Vital Signs

in Features

“I’ve always had an uncomfortable relationship with institutions,” Peggy Chinn, a professor of nursing, declares from the podium.

The audience laughs in agreement. They don’t tend to get along with authority, either. They’ve gathered at the University of Pennsylvania’s School of Nursing on a September weekend to find others like themselves at the first Rebellious Nursing! conference. For these nurses, who bring a far-left perspective that’s uncommon in their profession, the weekend promises to be part homecoming, part summit; part protest, part celebration.

These “rebellious nurses” know that the biggest struggles aren’t always the ones that have to do with blood and guts. The social issues that loom large over the country are impossible to ignore when bodies become battlegrounds, and when the effects of poverty and discrimination are seen up close in emergency rooms and clinics. At the same time, society isn’t always kind to nurses themselves; in the medical hierarchy, they’re often treated as less valuable than doctors. These nurses are here to plot and strategize, to win respect for their profession and quality care for their patients. They want to change the spirit of their profession through conversation, and to keep their colleagues to re-examine their approach to work.

The conference kicked off the previous evening at a converted warehouse in West Philly now used as a local arts center. I dutifully made my nametag on cardboard repurposed from a Quaker oatmeal box and tied it around my neck with rainbow yarn:  “I’m here because…I’m writing an article about Rebellious Nursing!” I received my hot-pink conference brochure with the RN! logo—a nurse’s gloved hand clasping a patient’s—emblazoned on the front.

Beer, vegan pizza, retro soda. Flannel, dirty Converse sneakers, thick-framed glasses. This felt close to home, not so distant from my own neighborhood. I’m no nurse: I’m squeamish about blood, and it’s been years since I took biology. But I am sympathetic to these self-proclaimed “rebellious nurses”—we are all frustrated by the obvious inequities in American health care. Who gets care, and who doesn’t? How are the sick treated, both as patients and as people? Unlike me, these nurses can make these changes happen. They take a risk by speaking up, but it’s their patients’ health and well-being that are at risk if they don’t.

This conference is the brainchild of Sarah Lipkin, a student at Yale’s own School of Nursing. After an undergraduate degree from Wesleyan, a flirtation with the film industry, and a stint in Portland, Lipkin now claims the title of “rebellious nurse” proudly, but her path to nursing wasn’t always clear.

“It just took me a long time,” she laughs, explaining the journey that brought her—hot-pink bangs, conch-shell tattoo, and all—to New Haven. After college, Lipkin decided to become a doula, a nonmedical caregiver similar to a midwife without medical training. Lipkin also spent time working with survivors of domestic abuse and recently released prisoners, before arriving at Yale in the fall of 2011 to begin a three-year master’s of science in nursing.

That February, she attended Yale’s leftist lawyering conference, “Rebellious Lawyering,” (or, affectionately, “RebLaw”), held annually at the law school. The conference brings lawyers together to discuss how they can use their expertise to work on behalf of people who face discrimination. She started thinking about ways to bring RebLaw’s approach to law into the field of nursing. The questions brought up at RebLaw about economic inequality, structural violence, and oppression seemed similarly applicable to nursing, but no one in the medical field was talking about them.

Throughout the conference, and over the following weeks, I talk to other nurses and students. They’ve worked in hospitals, clinics, schools, camps, hospices, classrooms, Planned Parenthoods, and outreach programs; they come from Baltimore, Philadelphia, Tennessee, Brooklyn, Seattle, Virginia, and New Haven.

The stories accumulate, and a common thread runs through them all: nurses witness horrendous treatment but lack the resources to change the system. A patient shows up in the ER complaining of pain, but colleagues deny pain medication because he’s probably a junkie looking to take a “rest” and get high. Another patient can’t speak English, but the staff doesn’t bother to call a translator. A fourteen-year-old girl gives birth as her mother screams at her and calls her a slut; a nursing student looks on and wonders what she can ethically do. Another teenager has a stillbirth; she’s black and living in the South and the hospital administers a drug test, even though there’s no legal requirement to do so; because there are traces of crack in her system, she’s charged with murder. A secretary shreds disability forms, hoping to encourage self-advocacy in a patient. An older woman isn’t given pain medication, because pain is just part of being old. Neither are some Hispanic or African-American patients, because “those women” are “too proud.” A patient of color is referred to as a “thug.” Rude and judgmental comments are made about a larger patient’s weight. An obstetrician has a busy day—so she encourages a patient to have a C-section.

Too often marginalized or underestimated, nurses themselves become targets. A nurse is a little too assertive—so co-workers whisper that she’s a lesbian. Nurses are sexually harassed by doctors or patients. A doctor dismisses a nurse’s suggestions about best how to treat a patient.

“Doctors make all the decisions,” complains Tino, a cardiac nurse from Tennessee, “but they’ll be in the room for a minute, while I’m in the room for twelve hours a day. I see different things.” If doctors treat cases and nurses treat people, and if nurses are powerless and doctors in control, ultimately, both the patient and the nurse suffer.

*

Peggy Chinn, the conference’s keynote speaker and professor at the University of Connecticut’s nursing school, was a key figure behind the 1980s radical nursing movement known as Cassandra, which promoted feminism in the health care profession. She quickly became something of a patron saint to Lipkin, who was beginning to envision a twenty-first-century reimagining of radical nursing. Armed with Cassandra’s archives of mimeographed newsletters, Lipkin realized that Chinn and others in the movement had begun a conversation that she wanted to continue. Lipkin reached out on Facebook and Tumblr in early 2012, searching for other “rebellious” nurses. “As a student, I have felt isolated in my attempts to find forums for progressive conversation around the practice of Nursing,” she wrote.

It turned out that Lipkin wasn’t alone. By that fall, she and her cohort of online supporters had made a lot of progress. “It’s kind of a miracle,” she reflects. “I don’t think this could have happened ten years ago.” By the following September, the group was ready to go: hundreds of nurses, students, and allies gathered in Penn’s Claire Fagin Hall for the first Rebellious Nursing! Conference.

The conference’s goals were bold and broad: the manifesto on the very first page of the pink booklet declared that they were “envisioning justice and liberation for health seekers, health workers and communities,” and uniting “to find inspiration, awareness, solidarity, and practical ways to impact health equity and health disparities.”

The manifesto was moving, but it didn’t say enough. Lipkin told me that nurses were “on the front lines, with patients, every day.” What did that mean? It was time to take some vital signs.

*

“What was your earliest experience with oppression?”

I’m at a workshop called “Anti-oppression fundamentals training for health care workers.” Jenna Peters-Golden, an organizer for a Philadelphia-based activist collective called AORTA (“anti-oppression resource and training alliance”), asks us to discuss the question in pairs. I sit in on a conversation with two nursing students, Amanda and Danie. Danie grew up moving between developing countries; her parents were aid workers, and their family was considered well-off just by virtue of having a house with four walls and a roof. Amanda grew up in Alabama, eating in restaurants where the customers were always white and the workers were always black. In school, she was shown the famous videos of children marching for civil rights and being crushed by fire hoses during Birmingham’s Children’s Crusade. She started crying and was sent home. “I never had a dialogue about inequality until I got to college,” she says. As they share stories, participants start to recognize similar inequalities in their work as nurses. Danie now interns at a local prison, and is conflicted about her work there. It’s her job to provide the best care she can to her patients, but she’s also part of a prison system she often finds unjust. “How can you support the inmates as patients while you’re working in this system of oppression?” she wonders.

After this activity, Peters-Golden poses another question: “Why did the Titanic sink?”

Answers rise from the audience. A lack of communication. Responding only to what was immediately visible. Overconfidence. Poor construction. Going too fast. Following the captain’s orders. Waiting too long before radioing for help.

Peters-Golden explains the idea of the “iceberg of oppression”—a theory that oppressive actions, visible on the surface, are enabled by systemic and institutional prejudices that lurk below. We’re here, she says, to “challenge the iceberg.”

Photo by Elaine Liebenbaum

But, I wonder, doesn’t the ship need to be steered? Where else is work—fast, careful work—more important than within the life-and-death world of a hospital? Isn’t there a case for patience, and working within the system? Then again, I don’t have to put on scrubs every day and go to work, witnessing injustice in a place meant for healing. In a workplace where decades of prejudice linger, but where minutes—even seconds—matter, the work still has to go on.

*

Almost every nurse can recall a moment that moved him or her to action. For Peggy Chinn, it was a death—not of a patient, but of the Equal Rights Amendment. In 1982, after decades of attempts to ratify the ERA, the amendment’s final deadline arrived, and it failed, three states short of ratification. Chinn happened to be at an American Nurses Association convention in Washington shortly after the amendment failed, and noticed that the guest speaker for the maternal and child health section was the conservative senator Orrin Hatch. She and likeminded colleagues “decided that that was all we could stand. We had to do something,” she tells me.

Chinn had discovered the essay “Cassandra,” written in 1860 by Florence Nightingale—a more radical figure than many think, she tells me, a character blurred by history’s lens. “I was talking about it constantly,” Chinn explains. She was particularly taken with one line: “Why have women passion, intellect, moral activity—these three—and not a place in society where one of the three can be exercised?” Even in the supposed post-women’s liberation era, this reminder of earlier times showed Chinn and the other women how far they had to go. They decided to adopt the essay’s name for their collective, which began in the early 1980s. Feminism became a powerful tool to reimagine the flaws in a field of work largely dominated by women, helping them connect general oppression of women to the way they were treated as nurses.

Yet Chinn stresses just how much vehement resistance there was to feminism within the nursing profession itself. “Nurses just resented feminism, or they were afraid of it,” she recalls. For its part, the feminist movement itself wasn’t much help, either. “They were trying to overcome the stereotype of the good wife, the submissive woman, obedient to the man. And they felt that nursing was just an extension of that male-created role.” Cassandra, an explicitly radical movement, valued nurses’ ability to nurture their patients while providing quality health care. Liberal feminists objected to this emphasis on traditionally feminine qualities.

Chinn seems to look back on that time with fondness, despite her frustration. It was a heady time, she says, when feminism felt new but was “starting to really blossom.” Earlier in her career, she had worked as a pediatric nurse at a hospital, but hated it. “It was like nurses didn’t have a brain and should just be a robot,” she explained. They were expected just to carry out the tasks they were given. She spent a few years in a physician’s office, which offered a better workplace, and then moved on to teaching college- and graduate-level courses in nursing at the University of Buffalo, and then at the University of Connecticut. “I knew I wanted to teach differently,” she explained. Inspired by Paulo Freire’s Pedagogy of the Oppressed, she developed a teaching technique that saw education as a process of solving problems, not memorizing information. It meant asking questions, and not necessarily having the answers.

Almost all of the nurses I talked to seemed satisfied with the technical aspects of their nursing education—the skills and the science. But they can face some unlikely adversaries in their non-nursing peers. Madeleine Wilson, a senior undergraduate nursing major at Penn unaffiliated with the Rebellious Nursing movement, describes her high-school self as a “very typical, straight-A, AP student that wanted to be a premed and have my elite life set out.” When her mother suggested the idea of nursing, she hated it. “No way someone like me who is top of the class is going to consider it,” she remembers thinking. She ultimately decided on nursing after being won over by the opportunities and faculty at Penn. Now, nearing the end of her undergraduate nursing degree with a minor in health care management from Wharton, she has spent four years hearing that attitude reflected in her peers’ opinions on nursing. “I get a lot of shit about how nursing is easier—‘why don’t you be a doctor?’” she explains.

Sometimes this tension plays out in institutional dynamics. Lola Pellegrino, who graduated from the school of nursing last year, told me found herself feeling uncomfortable in some of her classes. Once, she tells me, jokingly, a class on psychiatric nursing was so hetero- and gender-normative that she “wanted to throw a Molotov cocktail at the Powerpoint” in one particular lecture.

Lipkin tells me how the nursing school was an early avenue for women to be part of Yale: it was founded in 1923 as the first autonomous school of nursing in the country, and all eight of its deans have been women. YSN is progressive in many ways: it has a strong community of LGBT students, a respected midwifery program, and an academic approach that recognizes nursing as an important academic—as well as practical—field.

The Yale School of Nursing is far removed from the rest of the university. The school’s move this October to Yale’s “West Campus” site in Orange, Connecticut—a twenty-minute drive from our bench on Cross Campus—allowed the school to expand and improve its facilities, but it also moved the school away from the rest of Yale’s medical community. The seven-mile distance between the nursing school and the medical school seems to reflect stark differences in resource distribution. Commenting on the move, YSN nurse-midwife student Emily Martyn says she no longer feels like she is “in the middle of the medical community.” But while nurses undertake rigorous courses and provide important care, in the eyes of some, they will always be “just nurses.”

*

Beyond anatomy and physiology, it’s clear that there are bigger lessons that need to be taught in nursing school. After all, there’s no “Racism, Sexism, Ageism, and Homophobia 101,” but these problems are just as serious, many rebellious nurses might contend, as any medical emergency. Like illness itself, health disparities among minority or disadvantaged populations also bring suffering—just on a slower, and often more insidious, level. These societal problems are particularly dangerous in the life-or-death medical world.

That brings them to the elephant in the room: money. Nurses stare huge economic obstacles in the face on a daily basis. Health care is expensive, and people will often go without it if money’s tight. For patients on Medicaid or other forms of government-funded health insurance, reimbursement rates are so low that providers must see patients in rapid succession, which leads to lower-quality care. “You might not realize that something’s going on,” Martyn says. “You have to actually sit with a patient to hear what they have to say and give them the care they deserve.” For many providers and patients, taking that time is simply impossible. Obamacare, Pellegrino says, will “push us there…It’s a step in the right direction,” but change will likely be slow.

Even the division of labor between doctors and nurses reflects economic tensions: nurses, Chinn says, have the most power when they are “taking care of people who no one else wants to take care of”—that is, populations that don’t bring in money. For example, nurses have a lot of latitude when working on a Native American reservation, but in mainstream environments where they can compete with nurse-midwives and nurse-anesthesiologists, their authority is limited. And traditional avenues of advocacy might not be available, since most nurses aren’t unionized. The nation’s largest nursing union, Nurses United, will only accept nurses with certain credentials, excluding many nurses and medical professionals.

Chinn is blunt: “Systems are set up by physicians or administrators who are out to make the most profit. As long as our health care system is a profit-based system, this kind of thing is going to happen”—that is, quality of care will be affected by who can pay for it and how much doctors will make.

Emma Dorsey, a nursing student at Penn, tells me that she came to the conference because she believes that nursing is a radical profession and wanted to “connect with other radical nurses, learn from them, draw strength from them, and have some fun.” She writes that she gained “all of the above” as well a tattoo. Her biggest unanswered questions: “What next?  Can we make a publication? Can we have another? More, please! More! How can we make more nurse-managed clinics and build a radical health option for the poor?”

For Dorsey and others, this is the state of living and working in the space between questions and the answers. What gets these nurses from shift to shift is their renewed sense of purpose: the idea that new conversations can take place in emergency rooms, in clinics, and across the profession. I had gone to find the revolution, and I’m still trying to make sense of what I saw.  But the work of building a healthier world might just start with rebellion.

Julia Calagiovanni is a Managing Editor for the New Journal and a junior in Silliman College.

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