Vital Signs: Nursing in Transition 9781442603042

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VITAL SIGNS

Copyright © 1993 by the Authors. All rights reserved. No part of this book may be reproduced or transmitted in any form by any means without permission in writing from the publisher, except by a reviewer, who may quote brief passages in a review. Printed and bound in Canada Canadian Cataloguing in Publication Data Armstrong, Pat, 1945Vital signs : nursing in transition (Network basics series) Includes bibliographical references. ISBN 0-920059-59-7 I. Nursing. I. Choiniere, Jacqueline. II. Day, Elaine, 1952- . III. Title. IV. Series. RT82.A751993

610.73

C90-093924-9

The Publishers acknowledge the financial support of Canadian Studies and Special Projects Directorate of the Department of the Secretary of State, Government of Canada. Cover photo courtesy of the Ontario Nurses Association

VITAL SIGNS Nursing in Transition

Pat Armstrong Jacqueline Choiniere Elaine Day YORK UNIVERSITY

Garamond Press

CONTENTS Preface Women's Health Care Work: Nursing in Context

7 17

Pat Armstrong A Case Study Examination of Nurses and Patient Information Technology

59

Jacqueline A. Choiniere The Unionization of Nurses

89

Elaine Day Bibliography

113

Acknowledgements The articles in this volume grew out of a York Graduate Seminar on Women and Work. Pat had just completed a case study of a major metropolitan hospital and both Elaine and Jackie were drawing on their experiences as registered nurses to examine further the conditions and relations of nursing work. We thought the research fit together to expand our view of nursing, the most typical of women's paid labour. Peter Saunders and Errol Sharpe at Garamond Press agreed and offered strong support for our project. Publication was delayed by funding problems and, in those few years, the nursing crisis was transformed by state cut backs from a critical shortage to a considerable surplus. In revising the articles for publication, however, we found that the underlying pressures had simply become intensified. It is always risky offering an analysis of a current situation. It is particularly risky when every day brings fundamental changes. However, we are convinced that the issues identified here remain the most salient for an analysis of women's nursing work. We would like to thank the nurses who shared their experiences with us and who did so in spite of the enormous pressures on their time and emotions. We would also like to thank our families and friends, who put up with the pressures on our nerves. And finally, we would like to thank Kate Forster for her very professional and sympathetic editing work.

Pat Armstrong teaches Sociology at York University, is co-author of The Double Ghetto: Canadian Women and Their Segregated Work, A Working Majority: What Women Must Do For Pay, and Theorizing Women's Work and author of Labour Pains: Women's Work in Crisis. Elaine Day is a registered nurse who authored "A Twentieth Century Witch Hunt", a critique of the Grange Commission inquiry on nurses at The Toronto Hospital for Sick Children. She is a Phd candidate in Political Science at York University. Jacqueline Choiniere works as a researcher at the York Centre for Health Studies. She too is a registered nurse and Phd candidate at York.

Preface Nurses who refuse to work as nurses, nurses taking legal action against their employers, nurses demonstrating, even nurses on strike. Whatever happened to those women so carefully taught "to show wifely obedience to the doctor, motherly self-devotion to the patient and a firm mistress/servant discipline to those below the rung of nurse"?1 For well over a century, nursing has been equated with all that is womanly. The nurturing, caring, and comforting skills, the selfless dedication, and the accepted subservience to male authority that are often considered central to the work are the same skills and attitudes long associated with being a proper woman. In the late nineteenth century Florence Nightingale, that upperclass lady with the lamp, struggled to transform nursing into a respectable profession for the growing number of non-working-class women who were seeking alternatives to the confines of the Victorian household. The nursing schools developed in keeping with her philosophy were largely successful in establishing nursing as a recognized occupation that required formal education and that maintained high standards of

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care. But, in line with the ideas of women of her class and time, Nightingale's philosophy did not involve a challenge to women's traditional responsibilities. Her intent was more to take what she saw as the virtues of the home into the market than it was to free women from the relations of the home. The nursing schools that followed her approach were also largely successful in reinforcing a hierarchical structure of care and a particular view of women. Nursing was not just a job for females; it was a feminine job. The reforms associated with Nightingale both reflected and affected broader developments concerning women and their work. Similarly, current transformations in nurses and in nursing are part of widespread and fundamental changes in the conditions and relations of women's work. And like the changes of that earlier time, the consequences for the women who do the work are contradictory. These changes often serve both to enhance and to undermine women's claim that nurses perform highly skilled and valuable caring work that is critical to health, both to liberate nurses from old restrictions and to link them to traditional responsibilities. In the period after World War II, the economic boom and the rapid expansion of the welfare state created a growing demand for workers of both sexes. The upsurge in demand for women workers was particularly evident in the state sector, as many more jobs appeared in traditional female areas such as education, health, and social services. By the early 1960s, male wages were no longer keeping up with the rising prices. At the same time, money became increasingly necessary to pay for mortgages, transportation, food and clothing. Fewer and fewer women could contribute enough to their families' economic support by working exclusively in the home.2 The growing demand for workers combined with women's increasing need for money meant that women flooded into the labour force. In 1951, only one-quarter of women in Canada 15 years of age and over were counted as part of the labour force.3 By the late 1980s, the proportion had more than doubled. Indeed current estimates indicate that more than 70 per cent of women between 16 and 69 years of age are in the labour force at some time during the year.4 Forty years ago, threequarters of women did not work for pay; now nearly three-quarters of them do. Married women accounted for most of this increase. In the 1950s, the majority of the women working for pay were single, and close to 90 per cent of married women were not counted as part of the labour force.5 If married women did work for pay, the overwhelming majority quit when they had children, and their subsequent participation in

Preface / 9 the labour market was usually temporary or intermittent. Today, most of the women who are in the labour force are married, and most of these married women have children at home. By 1990, more than 90 per cent of the married women in the labour force had been there throughout the previous year.6 Unlike women of forty years ago, most women today face a lifetime of labour-force work, whether or not they marry and have children. And most women have little choice about taking on labour-force jobs. Between 1989 and 1990, real income declined for all families, but it declined least for families with two incomes.7 Women's pay made the difference. Many families could not survive today without women's income, and most would experience a significant decline in living standards if women did not work in the labour-force. During the postwar period, the increasing participation of women in postsecondary education reflected women's recognition that paid work would be a major part of their lives. The rising enrollment of women in turn affected their participation in the labour force and influenced their expectations about the kinds of jobs they would take there. In the early 1950s, three times more men than women received a bachelor's or first professional degree, more than six times more men received a master's degree, and only 11 women, compared to 191 men, were granted doctorates. "In 1987, women received 53 per cent of bachelor's degrees, 45 per cent of master's degrees and 29 per cent of doctorates."8 In the late 1980s, women constituted the majority of students in other postsecondary institutions as well. This increasing participation and increasing formal education did not guarantee women an equal place in the labour force, however. Throughout the postwar period, more than 70 per cent of women were found in just five occupational categories: clerical, sales, service, teaching, and health work. Moreover, these remained women's occupations throughout the postwar period. In 1991, women accounted for 80 per cent of those in clerical and health jobs and two-thirds of those in teaching jobs.9 Half of the women, but only one-quarter of the men, worked in the service industries. And the lower tiers of these industries, where women are concentrated, are characterized by job insecurity, few fringe benefits, low pay, little chance of promotion, low skill requirments, and a mismatch between the education of the workers and the demands of the job.10 Nearly one-third of employed women had only part-time employment, with the result that these women had even fewer opportunities for decent pay, promotion, and security. Even though the gap between male and female wages has narrowed somewhat since World War II, the earnings ratio showed little change throughout the 1980s, and most

10 / Vital Signs women are still paid significantly less than men. "For female full-year full-time workers, 1989 average earnings were $23,091 or 65.8 per cent of their male counterparts ($35,073)."" As women's participation in the labour force and in higher education grew, so did their membership in unions. Indeed, women's rate of unionization grew faster than their rate of labour-force participation and faster than the unionization rate of men.12 By 1986, 28 per cent of women employed full-time and 18 per cent of women employed parttime were union members.13 The majority of the women who belonged to unions worked in the public sector.14 But the economic boom and the expansion of the welfare state that drew many women into the labour force and allowed and encouraged them to improve their conditions of work seem to be over. The Free Trade Agreement with the United States signalled a new devotion to a market economy, one based on competition, private-sector standards of efficiency, and less government involvement in service provision. New technologies are eliminating and creating new jobs, at the same time as they are fundamentally reorganizing the way work is performed and controlled.15 The relatively secure and relatively well-paid jobs that characterized the postwar period are disappearing, replaced in many instances by part-time or part-year jobs that offer only limited rewards.16 Not surprisingly, the patterns in nursing are very similar to the overall patterns in the labour market. In 1951, there were only 35,138 graduate nurses in Canada and a mere 85,790 people were counted as health professionals.17 Almost all nurses—98 per cent of them—were women, and almost all of them were single. The introduction of hospital insurance and then medicare contributed to an enormous growth in health-care work throughout the next three decades. By 1986, the Census recorded 236,993 registered nurses and nearly half a million people employed as health professionals.18 About 70 per cent of the nurses were married, and slightly more than 70 per cent of them had at least one child at home.19 Some things had stayed virtually the same however. "There has been no appreciable change in the percentage of male nurses over the years." By 1986, 97 per cent of nurses were female20; more than threequarters of doctors and senior administrators were male. It was during this period of rapid growth after the war that the schools fashioned in the Nightingale tradition closed. Nurses-in-training, as they were called in the 1950s and '60s, took classes in the hospital, lived in hospital residences, were pressured to follow strict rules of dress and decorum, and provided much of the nursing care. But the increasing availability of other kinds of education and of other kinds

Preface /11 of jobs, combined with a rejection by many of the strict rules and heavy work in the hospital, lowered the enrollment in nursing schools. These developments contributed to the move of most nursing education to community colleges, and to the movement of nurses out of hospital residences. More and more women have selected university nursing programs, with some taking the new degrees offered at the graduate level. By the end of the 1980s, nursing work had been transformed. Although "fully 93 per cent were employed in direct patient care/' most nurses now work in giant hospitals that are characterized by a rigid bureaucratic hierarchy segregated according to sex and race, power and pay, specialty and education.21 And although nurses continue to be by far the largest occupational group, there are now hundreds of other occupational categories within the health-care system. Both technology and administrative concerns play an increasingly important role in structuring patient care and the organization of work. The large numbers of women with advanced education who were moving permanently into the labour force became increasingly frustrated by the limitations and inequities women faced there. Now that they were in the labour force for the long haul, women had more time and incentive to develop collective strategies for change. The professional associations, first formed in the early part of this century, moved away from a primary focus on elevating "the standards of education and promotion of a high standard of professional honor"22 and on establishing a code of ethics.23 Increasingly, they engaged in collective bargaining, although they continued to oppose strike action.24 Early in the 1970s, largely as a result of labour legislation, nurses began to organize within a union structure and to consider strike action.25 Today, 80 per cent of nurses are covered by collective agreements.26 Collectively and individually, nurses have fought against the continuing segregation of women into jobs clustered at the bottom of the hierarchy. They have fought against their poor working conditions and their low pay. They have demanded more power and more respect, insisting that their jobs are not only skilled but also require a great deal of effort, involve considerable responsibility, and are often done under difficult working conditions. These conditions and relations of work, however, are often rendered invisible by the assumptions made about women's natural capacities and by efforts to keep women in their place as a cheap source of relatively compliant labour. Not surprisingly, nurses in particular have become increasingly unwilling to accept a subservient place. But, as is the case in the economy as a whole, the long boom in health care is over. Consistent with the new emphasis on less govern-

12 / Vital Signs

ment, the federal state has significantly reduced financial support for health care, and provincial governments have followed suit. In the era of Free Trade, there is a new emphasis on running health care as a business.27 The multitude of commissions set up to examine health-care policies have begun by leaving the cutbacks unquestioned and have accepted the new emphasis on efficiency and cost-effectiveness.28 They have looked to "private sector management techniques" and "more efficient and cost effective use of nursing staff by such initiatives as reducing or eliminating non-nursing responsibilities, use of labour-saving and mechanical devices, and job sharing or other reduced work week options."29 Nursing work is again being transformed and jobs are being eliminated or made insecure. For the first time in many years, nurses are being laid off, and those who remain have to work harder, under worsening conditions, with less and less opportunity to provide the care they have the skills to provide. This book is about these changes in women's nursing work. The first chapter looks at the historical developments that have led to the current conditions and relations of nursing. The second examines the role of technology in structuring this women's work. The final chapter analyses some of nurses' recent struggles for change. Although each chapter has been written by a different author, they are all guided by a feminist analysis that assumes being a woman makes a difference and that takes the side of women. Moreover, the three chapters share an approach that understands women's nursing work within the context of developments in the political economy and that relates women's position as nurses to that of women throughout the country. It is necessarily an unfinished story, as nurses continue to fight for the structures and relations which will allow them to do the work they want to do. Pat Armstrong September 1992

Preface /13 NOTES 1.

Judi Coburn, "'I See and Am Silent7: A Short History of Nursing in Ontario 1850-1930," in Women at Work: Ontario 1850-1930, ed. Janice Acton, Penny Goldsmith and Bonnie Shepard (Toronto: Women's Educational Press, 1974), 139.

2.

Pat Armstrong and Hugh Armstrong, The Double Ghetto: Canadian Women and Their Segregated Work (Toronto: McClelland and Stewart, 1984), Chapter 6.

3.

Ibid., Table 1.

4.

Statistics Canada, Canada's Women: A Profile of Their 1988 Labour Market Experience (Ottawa: Statistics Canada, 1992), Table 2.

5.

Armstrong and Armstrong, The Double Ghetto, Table 20.

6.

Statistics Canada, Canada's Women, Table 2.

7.

Statistics Canada, Family Incomes: Census Families (Ottawa: Supply and Services Canada, 1992), 9.

8.

Statistics Canada, Women in Canada: A Statistical Report, 2nd edition (Ottawa: Supply and Services Canada, 1990), 47.

9.

Calculated from Statistics Canada, The Labour Force (Ottawa: Supply and Services Canada, 1992), Table 14.

10. Harvey Krahn, Quality of Work in the Service Economy (Ottawa: Supply and Services Canada, 1992). 11. Statistics Canada, Earnings of Men and Women, 1989 (Ottawa: Supply and Services Canada, 1990), #7. 12. Canadian Advisory Council on the Status of Women, Integration and Participation: Women's Work in the Home and Labour Force (Ottawa: CACSW, 1987), 103. 13. Statistics Canada, Women in Canada, 90. 14. Heather A. Clemenson, "Unionization and Women in the Service Sector," Perspectives on Labour and Income 1, #no.2 (Autumn 1989), 40.

14 / Vital Signs 15. See Pat Armstrong and Hugh Armstrong, 'Taking Women Into Account: Redefining and Intensifying Employment in Canada/7 in Feminization of the Labour Force, ed. Jane Jenson, Elizabeth Hagen, and Ceallaigh Reddy (Oxford: Polity Press, 1988). 16. Economic Council of Canada, Employment in the Service Economy (Ottawa: ECC, 1991). 17. Dominion Bureau of Statistics, Census of Canada: Labour Force (Ottawa: Queen's Printer, 1966), Table 8. The term "professionals" is that used in the data collection. There is a great deal of debate about what "professional" means, and the use here should not be understood to mean that the issue is resolved. 18. Statistics Canada, Nursing in Canada, 13. 19. Statistics Canada, Canadians and Their Occupations: A Profile (Ottawa: Supply and Services Canada,1989), Table 1. 20. Statistics Canada, Nursing in Canada, 13. 21. Employment and Immigration Canada, The Labour Market for Nurses in Canada (Ottawa: Employment and Immigration Canada, 1989), 3. 22. Helen Mussallam, "The Changing Roles of Professional Nurses' Associations," in Canadian Nursing Faces the Future: Development and Change, ed. Alice Baumgart and Jenniece Larsen (Toronto: C.V. Mosby, 1988), 401. 23. Phyllis Marie Jensen, "The Changing Role of Nurses' Unions," in Baumgart and Larsen, Canadian Nursing Faces the Future, 460. 24. Janet Kerr, "Unionism and Professionalism: Conflicting or Compatible Processes?" in Canadian Nursing: Issues and Perspectives, ed. Janet Kerr and Jannetta MacPhail (Toronto: McGraw-Hill Ryerson, 1988), 212. 25. Ibid. 26. Eleanor Adaskin, "Organized Political Action: Lobbying by Nurses' Associations," in Baumgart and Larsen, Canadian Nursing Faces the Future, 477. 27. Pat Armstrong and Hugh Armstrong, Health Care as a Business: The Legacy of Free Trade (Ottawa: Canadian Centre for Policy Alternatives, 1991).

Preface /15 28. Douglas E. Angus, "A Great Canadian Prescription: Take Two Commissions and Call Me in the Morning/' in Restructuring Canada's Health Service System: How Do We Get There From Here? ed. Raisa Deber and Gail Thompson (Toronto: University of Toronto Press, 1992), 55. 29. Ibid., 56.

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Women's Health-Care Work: Nursing in Context Pat Armstrong

Introduction Nursing work is women's work. It is women's work both in the sense that the overwhelming majority of those who do the work are women and in the sense that the skills and relations involved are those most characteristic of women's work. Like the other work of women, nursing reflects the complex interaction of ideological, economic, and political forces that women have been shaped by, have helped shape, and have responded to in a variety of ways. In order to understand the limits and possibilities of this women's work today, it is necessary to set it in the context of the past and of the larger society. It is necessary to examine the development not only of health-care structures but also of the political economy in which they are embedded and of the struggles around their development.

18 I Vital Signs

The many explanations for the current structures and relations of health care in general and of women's work in particular are mainly variations on two basic themes. The first kind of explanation sees changes in health care as progressive, linear, and largely inevitable developments that reflect a response to agreed-upon social needs and to technological breakthroughs that also serve these needs. The division of labour, the hierarchical structures, and the enormous differences in power and pay are understood as not only inevitable but desirable: a rational means of allocating the best person to the job and of ensuring efficient operation according to bureaucratic, objective criteria. What is called specialization is seen as desirable because it is understood to reflect increasing knowledge and to enhance job satisfaction. The danger of separate components flying apart is countered both by the hierarchical structure and by a common ideology and organizational commitment. To a large extent, developments in health care and in nursing work are explained within the institutional structures devoted to care, with only limited reference to the economic, political, and social relations outside their boundaries. In social science terms, this perspective is most commonly found among those adopting a structural functionalist approach. The second kind of explanation focuses not on consensus and response to common social needs but on conflict and interests served. The healthcare system and the division of labour within it are understood in the context of a political economy characterized by an uneven distribution of wealth and dominated by mainly male efforts to increase profits and power. The division of labour, the hierarchical structures, and the inequalities are seen primarily as the products of, on the one hand, efforts by those on the top to increase control and profits, and, on the other, efforts by those on the bottom to resist these pressures. Specialization and technological developments are understood not simply as a response to social needs but also as the result of struggles, of attempts to increase power, and of choices made that are often based on questions of control or profit rather than of common social needs. In this analytical framework, developments in health care are understood as much more contradictory, and people are seen as much more active in shaping their own lives. This perspective is most frequently called a political economy or historical materialist approach. It is this second theoretical approach that forms the basis of analysis in this chapter. This perspective is used because it is better able to explain how a particular group of men came to establish their power, even when there was little evidence that their methods worked, and why this power is currently being challenged not only by nurses but also by patients. Unlike the structural functionalist approach, the polit-

Women's Health-Care Work /19 ical economy perspective leads to an understanding of how people have shaped their own lives, although not under conditions of their own choosing. It thus permits us to think about how we could establish alternative structures and practices within the health-care system. Developments in health care and in nursing work are located within the context of a changing political economy that continues to segregate and subordinate women's work at the same time as it creates conditions that encourage women to revolt against this segregation and subordination. Changes in women's conditions and in women's consciousness have led to nurses' increasing demands for the right to greater control over their work and for changes in their conditions. The results of their efforts, however, are frequently contradictory, often serving at one and the same time to improve their position and to undermine it. The Establishment of Male Medical Dominance The development of nursing work has been profoundly influenced by the emergence of male medical dominance. Women have always been central to the provision of heath care both in and out of the home. But from the beginnings of white settlement in North America, male doctors trained in allopathic, or what we now call traditional, medicine struggled to establish their position at the top of a health-care hierarchy. They worked to prevent some people from practising any form of medicine and to limit what those who remained in health care could do. The successful struggle of this particular group of men to organize their monopoly and to consolidate their power over others helped ensure that nursing was women's work and that it was subject to medical authority. Consequently, in order to understand the position of nurses today and to analyse their potential for power, it is necessary to examine how medical dominance was initially established. This section briefly outlines the development of medical dominance and the impact of this development on women's place in health-care work. Many aspects of health care have been, and continue to be, primarily women's work. 'The typical Ojibwa woman could set a broken leg, stitch a wound, and gather and administer medicinal plants for dozens of ailments."1 European women arrived equipped with "mother's instructions and prescriptions" to treat everything from convulsions to severed fingers. And of course, as The Canadian Home Cook Book2explained, women were "responsible for the health of the household" through the production and preservation of food, the ventilation and heating of rooms, the clothing and supervision of children, and the application of what The Great Nineteenth Century Medicine Manual4 termed "simple home remedies and good nursing" for the sick.

20 / Vital Signs

From the earliest European period, women were also centrally involved in the provision of formal care. North America's first hospital was founded in Quebec in 1639 by three Augustinian nuns, with funds donated by a French duchess.5 As individual benefactors and as members of various organizations, women established many other hospitals, initiated "Health Talks for Mothers/' and were actively engaged in providing "Care and Treatment of the Aged Poor."6 Furthermore, it was nuns, often from wealthy families, lay nurses "from the domestic service class,"7 and, by the nineteenth century, nurses trained in the Nightingale tradition as well as volunteer women with "household occupations" who constituted most of the health-care labour force.8 Until well into this century, most babies were born at home with assistance from mid wives or women neighbours. Childbirth was treated as a normal and natural process rather than as a medical event. Application was made for the creation of a midwifery school in Quebec as early as 1754, an organization of mid wives existed in that province as late as 1921, and some continued to practise until the introduction of hospital insurance in 1961.9 Most of the women who did this work "were educated and respected members of their communities, with above average wealth."10 Although it was primarily women who were responsible for maintaining health and healing the sick, the state and male doctors were also involved in the delivery of medical services from the beginning of the colonial period. The state was engaged in overseeing the health care of military personnel, in providing institutional services for the homeless as "part of the poor relief," and occasionally in paying doctors' salaries in early settlements. As the colonies developed, the state also became involved in screening immigrants to prevent the spread of disease.11 Towards the end of the nineteenth century, women's organizations concerned about high mortality rates among children and doctors armed with theories about bacteria successfully pressured the state to develop sanitation, immunization and inspection measures as well.12 From 1788 on, the state had empowered certain "medical men to examine prospective practitioners of medicine."13 In granting licensing powers to a select group of men, however, the state initially ensured neither the elimination of alternative healers nor patient confidence. As medical doctor David Naylor14 explained, the emergence of rival schools such as homeopathy and eclecticism can be taken as evidence that there was no firm scientific consensus concerning most aspects of practice. Until the latter third of the nineteenth century, the substantive bodies of theory and practice developed by practitioners of the healing arts were usually fanciful or downright dangerous. Allopathic physicians

Women's Health-Care Work / 21

came to dominate at the beginning of the twentieth century only after lengthy struggles and some medical successes.15 Even then, their success was more a reflection of their organizational strength than of the usefulness of their diagnosis or treatment. Licensed practitioners faced internal divisions and external opposition, primarily because their treatment frequently failed. The germ theory was not accepted until the late nineteenth century. Before that time, treatment by doctors who had been in contact with the sick or with cadavers was often dangerous, given that these practioners did not use antiseptics or even carefully wash their hands. Conseqently, nurses and patients often contracted fatal diseases in hospitals.16 Moreover, the brutal, frequently irrelevant, treatments use for diseases such as cholera encouraged many people "to abandon the regular medical men and turn to those offering less daunting regimens/'17 Those offering the less daunting care were often women. Early conflicts centred on how and where practitioners were trained, who could practice, and how fees were established. These conflicts were settled near the middle of the nineteenth century when medical schools affiliated with universities, and when the monopoly of self-governed allopathic doctors was secured. This victory, combined with licensing requirements and standardized as well as upgraded training, made allopathic medicine both more effective and more respectable. At the same time, it restricted formal preparation to those from higher social classes and those practising particular techniques. It also ensured that medical doctors shared social as well as academic preparation, bringing them closer together and increasing their capacity to organize to protect their interests. "Stricter requirements weeded out not only the poor,...but also female candidates."18 Women were allowed into some university programs by the 1850s. But women were not admitted to Canadian medical schools until two women's facilities were set up in 1883, as a result of pressure from the women's movement in general and from Jennie Trout and Emily Howard Stowe in particular. The women's schools were separated from those for men, however, and most men in medicine continued to fight against the threat to their status and income posed by women. "Internships and residencies were commonly denied women. Male physicians often were reluctant to consult female colleagues."19 The growth of feminism undoubtedly contributed to the movement of some women from comfortable families into these schools, but limits on the number of women admitted into medical schools remained until the 1960s.20 Between 1883 and 1964, only 1,550 women graduated from Canadian medical schools.21 This is compared to the nearly 20,000

22 / Vital Signs

men practising medicine in the early 1960s.22 The few women who earned their medical degrees were pressured to act like the male doctors, particularly in relation to the many women who worked as nurses. Throughout this period, doctors had become increasingly concerned about women's practices, especially in delivering babies. A surplus of medical school graduates in the mid-nineteenth century made male doctors particularly anxious to eliminate competition from the unorganized midwives and to use childbirth as a means of access to family patronage. In 1865, the state granted organized doctors in Ontario the exclusive right to attend childbirths, establishing a precedent quickly followed in most other parts of the country.23 The gradual medical takeover of childbirth and the elimination of midwives was at least as much a result of doctors' political strength as it was of their superior skills or techniques. Indeed, the techniques themselves could not be separated from these political struggles. A monopoly over the administration of chloroform and the use of surgical tools24 allowed doctors to promise intervention to aid the birth process and less painful childbirth, but not to achieve lower death or injury rates. A Saskatchewan medical officer reported in 1919 "that maternal mortality was much higher in the 50 percent of confinements attended by medical men." Moreover, "a very large number of women were confined without either nurse or doctor in attendance, and in these cases, maternal mortality was much lower."25 When he presented this information to the doctors' association, he "was very strongly taken to task by some of the members for even compiling these figures."26 Although these higher mortality rates were at least partly attributable to the fact that doctors often handled the higher-risk cases, it is also the case that doctors' greater tendency to surgically intervene and to carry germs from other patients often put women in danger.27 The doctors' inexperience, their fees, and their uneven distribution across the country meant that many women continued to rely on the more familiar, and often less dangerous, services of midwives or neighbours. When Lady Aberdeen, the President of the National Council of Women of Canada, suggested in the late nineteenth century that her Victorian Order of Home Helpers deliver babies, as well as offer simple nursing care and housekeeping instruction, both doctors and the nurses trained in the Nightingale tradition objected. The doctors' opposition was based on their "determination to maintain a monopoly on obstetrics, but the nurses endorsed it in order to retain favour with doctors and to protect their own precarious status. If the nurses challenged the male doctors by approving of home helpers, they would jeopardize their position."28 The opposition was successful. The Victorian Order of

+Women's Health-Care Work / 2

Nurses, established in 1897, included only nurses trained in hospitals. These nurses were not midwives and served "the very poor people who [could] not well afford to pay a doctor/'29 They thus posed little threat to nurses' training or to doctors' income. However, as nurses acquired more formal education, doctors continued to campaign vigorously against their "ill-directed excursions beyond their proper latitude."30 By the beginning of this century, allopathic practitioners had settled many of their internal differences, strengthening their position in relation to the state, to nurses, and to patients. Increasingly, they were able to claim therapeutic successes based on a few scientific breakthroughs. And they took much of the credit for the rapidly declining death rates which followed the introduction of state health measures and the improvement in nutrition. As was the case for health improvements in general, doctors were able to claim credit for the overall decline in maternal mortality rates. Undoubtedly, the discovery of germs and of various medical techniques helped control "septic infection, haemorrhage and the direct effects of pregnancy toxaemia."31 But improvements in nutrition and sanitation, the lightening of workloads, and the reductions in pregnancies were also very important in decreasing the number of women who died giving birth. As Thomas McKeown32 has pointed out, "we owe the transformation of health during the past three centuries primarily not to what happens when we are ill, but to the fact that we do not so often become ill. And we remain well, not because of specific measures such as vaccination and immunization, but because we enjoy a higher standard of nutrition and live in a healthier environment." Also important in their success were the political efforts of the doctors' professional associations and their close class ties to those making the decisions. "These efforts gave organized medicine state-supported and virtually unassailable authority over the growth of the profession and the nature of its work." They resulted in "the protection of solo, fee-for-service practice against alternatives modes of organization,"33 and a hierarchical structure in health-care. At the same time, these efforts assured the dominance of a medical, curative, hierarchical, and patriarchal form of medical practice. This allopathic approach emphasized treatment rather than prevention and, not incidentally for nursing work, diagnosis rather than care. It was based on an engineering model of the body, which views the body like a machine made up of interconnected parts that can, to a large extent, be separately treated. While this model has allowed the refinement of techniques, the emphasis on body parts downplays the importance of care of the whole person, the kind of approach still taught to nurses. It

24 / Vital Signs

assumed that doctors require largely unquestioned authority in order to carry out their treatment and that their orders should be carried out largely by nurses. This authority was justified by what were called doctors' objective diagnoses, which were assumed to be based purely on scientifically established knowledge. Yet there is little evidence that medical doctors offer objective diagnosis; that is, diagnosis free of social values and of their social context. Indeed, there is significant evidence that today many doctors operate as men with particular kinds of world views. This is especially apparent in their treatment of women. For example, doctors prescribe twice as many tranquilizers to women as they do to men, a practice that cannot be explained by symptoms alone and that is much better explained by doctors' attitudes towards women.34 There is also evidence to suggest that much of medical treatment does not conform to the rigours set out in the scientific paradigm. This paradigm assumes that treatment can, and has been, proven effective. However, it is very often difficult to take a sufficient range of factors into account in developing and testing treatment. Moreover, too often those tests that could be done have not been done. The drug DES provides just one example of the problem. Prescribed to prevent miscarriage, the drug not only failed to do the job; it also caused cancer in many of the babies born to mothers prescribed the drug. There is evidence to suggest that there was no demonstrated effectiveness of the drug in clinical tests and that it produced cancer in mice.35 Although the rules for scientific investigation are more sophisticated today than they were when allopathic practioners first gained dominance, diagnosis and treatment frequently remains a best guess rather than a proven effective cure. Medical doctor Michael Rachlis and coauthor Carol Kushner36 claim that "Most of the therapies provided in our health-care system have never been properly validated." Furthermore, few of the physicians "have the skills in critical appraisal needed to weight evidence from the scientific literature" when the research is available. The dominant approach also focused on individual treatment, which served primarily to isolate the patients' problems from their social environments. One American study found that physicians allowed their patients an average of eighteen seconds to decribe their symptoms.37 This was barely enough time to outline biological responses, and left no time at all to consider social relations. The details of family and home life were left to the nurses to address, if at all. After more than a century of struggle, allopathic physicians trained in universities were able, with state support, to prevent some men trained

Women's Health-Care Work / 25

in such techniques as homeopathy or hydropathy and almost all women, whatever their approach, from charging for diagnosis and treatment of the sick or injured. Nurses could practise only with permission from, and under the authority of, this exclusive set of medical men. The early female nursing staff had offered little collective resistance to this domination. There were a number of reasons for this. Nuns, the "ladies in black and grey who worked for the love of God and the Church," had begun by committing themselves to obedience, and most of them had no place else to go.38 When the training for non-religious nurses was introduced as a result of "the need felt by the physician and surgeon for more intelligent assistance from the attending nurse in the advanced scientific treatment of his patients," these nurses too were kept cloistered in tightly supervised residences and exposed to thorough obedience training.39 In a letter written to her family in 1931, student nurse Vera Ernst McNichol explained that "After breakfast the nurses-in-training must assemble in the office to answer roll-call and repeat in unison the Florence Nightingale Pledge before going on duty at 7 a.m. We have to back out of the office as we dare not turn our backs on the superintendent."40 As students with little power, they provided a cheap source of labour. As late as the early 1960s, they performed almost a third of all bedside care.41 As "trained nurses," most kept regular appointments only until they were married. And many worked in isolation from other nurses. "Private duty nursing, or the employment of nurses by families to provide nursing services in the home, was the primary field of employment for 60 per cent of the registered nurses in the 1930s and continued as a prominent choice of work until the late 1940s."42 Nurses' short tenure and their scattered places of work made collective organizing difficult. Not surprisingly, the earliest attempts at organizing nurses were made by nursing supervisors, single women who were primarily concerned with differentiating between "trained" and "untrained" nurses.43 By making nursing a "female-only" job that could only be done by single women, male physicians and others were also encouraging high turnover that would limit opportunities for resistance. In Quebec, regulations adopted in 1943 to register nurses reserved the profession for women. This restriction was not abolished until 1969.44 In spite of the severe limits placed on the possibility for collective resistance, many women refused to passively accept "their place" or their conditions. In her autobiography, Ethel Johns45 described how, as a student nurse at the turn of the century, she was expected from her first day in training to provide direct patient care from seven in the

26 / Vital Signs

morning until seven at night. "If we could be spared, we were given one afternoon a week beginning at two o'clock." With little financial support, she argued, those in charge of the hospitals "can hardly be blamed for regarding the school as a heaven-sent and perfectly justifiable source of cheap labour. Patients had to be nursed and nurses had to be trained—it was just as simple as that...." Although she accepted firm rules of decorum and rigid lines of authority as necessary for nursing, she took part in a written protest students sent to the Board of Directors when four graduate staff were dismissed. In response, she was reminded of the contract she had signed and her written promise "to obey the authorities under all circumstances." These same working conditions, and the example of doctors' collective strength, encouraged some Ontario nurses to seek control over registration as early as 1905. But, because they were internally divided by competition among those with various kinds of training, lacking the class ties to those in power enjoyed by the male doctors, limited by high turnover rates, and opposed by the state as well as by doctors, the Ontario nurses did not acquire full control over admission and certification until the 1950s46. "Nova Scotia enacted the first law in Canada to register nurses in 1910. Manitoba followed in 1913, with New Brunswick and Alberta in 1916 and British Columbia in 1918." But in British Columbia, for example, it was not until 1935 that nurses gained the power to certify nurses.47 Even with registration by nurses, doctors continue to have a significant say in nurses' education and work. Following the doctors' example of seeking state sanction for their right to admit and certify members did not help the nurses acquire the same kinds of power that doctors enjoyed, however. Nurses' power was restricted by the fact that doctors were already in a position to have an important influence on the definition of nursing and the extent of nurses' rights. Moreover, the doctors' strategy for gaining power failed to work for nurses because most nurses were employees rather than independent employers like doctors and thus had little direct control over their working environments. Furthermore, the fact that nurses were women in a patriarchal society severely limited their access to power.48 Thus, the certification strategy initially served more to strengthen the hierarchy than it did to strengthen nurses in their daily work. The certification strategy, like that of Nightingale, did, however, serve to counter the assumption that much of the skill involved in nursing work comes naturally to women. It reinforced the argument that nursing is skilled work that requires hours of learning and high standards of care. And it helped to carve out a particular area of competence for nurses, distinguishing their skills and responsibilities from those of other

Women's Health-Care Work / 27

health-care workers. But it did not give them the right to determine their working conditions, to question doctors' authority without fear of retribution, to choose their patients, or to determine what they or others could do to patients. Other female-dominated health-care occupations, such as nursing aide, technician, and therapist, began to appear in the first half of this century. But medical men were already in a position to exert considerable influence over decisions about what kind of training these groups would receive and what kinds of procedures they could follow. And they ensured that the rights and responsibilities of each group were carefully circumscribed. The few women who, often supported by women's organizations and feminist ideology, made it into medical school, were trained in the same manner as their male colleagues and faced severe structural constraints that limited alternatives to the dominant medical model.49 Like nurses, then, these new occupational groups offered little collective and concerted opposition to the hierarchical structure and rigid working conditions. Until the 1950s, women continued to provide most of the care in and out of the market and to retain much of the responsibility for the nation's health, but authority rested with the state-sanctioned, predominantly male medical profession. It was these men who decided who had what done to them, where, by whom, and for how long. The Establishment of Modern Medical Care The struggle for medical dominance influenced, and was influenced by, the establishment of the modern health-care system under the umbrella of the state. The emergence of both hospital insurance and medicare initially served to reinforce doctors' power at the same time as it transformed nursing work and provided many more paid jobs for women. Most nursing work was integrated into the large bureaucratic structures funded by the state but still largely directed by doctors. This section traces the development of our state system of care and looks at how it helped structure women's nursing work. From the earliest days of the colonies, the state had been involved in providing health care for those who could not be cared for at home. For the most part, the state supplied various kinds of support to aid those offering services, rather than directly offering state care. It was, at most, "'state medicine' for the underprivileged."50 After World War II, the state began to provide unemployment insurance, pensions, and other social services. Along with this socialization of the social wage51 in the prosperous years, however, went the transformation of state involvement and of health-care services. In establishing stable and relatively

28 I Vital Signs

unlimited funding for first hospital care and then medical services, the state was both responding to and influencing political demands, technological change, the medicalization of daily life, and the new health and social problems created by economic development. It was also influencing the capacities of women to deal with old or new problems at home. Hospital services grew enormously, as did paid jobs for women. The state not only granted certain kinds of doctors a monopoly over medical practice; it also organized the public funding of their private services. Until the end of the nineteenth century, doctors had treated patients primarily in their homes and nurses had mainly worked in private practice. Hospitals, usually operated by charities or religious groups, were reserved for the sick poor —the last alternative for many.52 Particularly after World War I, however, new techniques and new standards of cleanliness made "hospitalization relatively safer for treatment" and increased hospital use by both doctors and patients, in the process altering costs and billing.53 After World War II, state subsidies stimulated considerable hospital expansion. The state was responding to demands made by unions, women's organizations, and various other groups who had "come to expect that a good many reforms on their behalf will be put into effect after the war."54 It was also responding to the financial difficulties of hospitals, to doctors' demands for facilities and payment, to the emergence of new forms of health problems, of treatment and of technology. It was encouraged by a booming economy and guided by a Keynesian philosophy that saw state funding as a means of maintaining a healthy economy. Following the example set by the CCF government in Saskatchewan, the federal government began in 1958 to implement a hospital insurance scheme to cover operating costs as well. "The services were to be provided by independent parties—the hospitals, for the needs of second parties—the patients, as ordered by still other parties—their physicians. It was almost like signing blank cheques, leaving others to fill in the amounts."55 Since doctors determined admittance, release, and treatment, the amounts were filled in primarily by them. Although many women worked in or raised money for these hospitals, women remain largely invisible in analyses of the process leading to state hospital insurance, perhaps because they were not consulted and had no recognized say in decision-making.56 But whatever the part played by these women in the development of universal coverage, the transformation and growth of hospitals that followed the introduction of federal hospital insurance saw the declining power of nuns and charitable ladies. Doctors and other state appointees increasingly took centre stage, while the funding of hospitals rather than medical care

Women's Health-Care Work / 29

"encouraged people to use high cost hospitals rather than lower cost services elsewhere/'57 More and more nurses worked in hospitals, under the surveillance of a large number of people and subject to a plethora of rules. Medical insurance was more controversial, at least from the doctors' viewpoint, than hospital insurance. It thus took longer to develop and was surrounded by more controversy. Both Soderstrom's and Taylor's analyses of the process leading to the introduction of medicare have revealed the opposition from men in medicine, in insurance, and in small business. But in spite of this opposition the Royal Commission on Health Services (the Hall Commission) concluded that "no enlightened government can ignore that the economic capacities of its citizens to be productive depends upon their health and vigour as much as upon education."58 Many large employers, faced with union demands for medical coverage in their contracts, agreed.59 So did unions and many community groups dominated by women. The Canadian Nurses Association presented a brief to the Commission although "no recommendations were made on the overall organization of health services or their financing."60 But few women actually participated in the decision-making process. Taylor pointed out that the only woman on the Hall Commission was also the only native French-speaking member.61 When the Medical Care Act was finally passed in 1966, the doctors had lost the battle to limit state involvement to paying the bills of the poor, but they had won many others. The Act was "not designed to change the structure of medical practice or to interfere with the authority of physicians but only to pay for medical care on the traditional feefor-service basis."62 Fee-for-service meant doctors were paid on a piecework basis. Thus, overall income was determined by how many patients physicians saw and what they did with and for them. And how many patients they saw and what they did to them was up to the doctors. Payment was guaranteed by the state. As a result of medicare, doctors' hours of work decreased, as did the number of house calls and telephone conversations, while their income increased.63 Insurance, drug, and medical-equipment companies also had some victories. Market forces continued to prevail in these areas as well, with the added benefit that the state became a major purchaser and one that guaranteed payment. Nurses, however, were not allowed to bill medicare directly for their services. This did not change until, in response to pressure from nurses' organizations, the 1984 Canada Health Act opened the door to this possibility. But to date no province has taken up the federal offer, and nurses remain outside the fee-for-service regime.

30 / Vital Signs Both the engineering approach and the interventionist strategy have been reinforced by state payment systems based on services rendered. With the introduction of medicare, "there has been a marked tendency for the number of relatively higher priced services to increase much more than the lower priced." Research in Quebec suggests that such increases "largely reflect changes in physicians' behaviour—their billing practices and the acts they decide to perform."65 The increases also reflect the growing reliance on technology and the proliferation of specialties in health-care. These have been encouraged by the engineering model of the body that views it as mainly separate parts. These tendencies were promoted as well by the profit basis of the firms' developing technology. More reliance on technology means more profits, and thus companies making these goods have a vested interest in extolling their virtues, downplaying their negative aspects and encouraging their use. Specialization, technology and the engineering model have also had an increasing impact on nursing work, as more and more nurses are pressured to become specialists and as more of their time is spent on treatment rather than on care. The early development of a medical-care system in Canada was characterized by the struggle of some male physicians to eliminate other approaches to health care and to establish their authority over others in the health-care field. They acquired their dominance primarily through a state-legitimated monopoly over services, with assistance from state regulations and payment methods. The later expansion of hospitals, encouraged by state funding, supported and largely directed by such doctors, initially served to consolidate and extend their powers.66 Medicare, though strongly opposed by most doctors—and by specialists in particular—increased doctors' pay and improved their working conditions,67 while the fee-for-service payment method left much of the control in licensed doctors' hands. However, the rapid development of state health-care systems in general and of hospitals in particular also contributed to the growing strength of other, mainly female, workers as well as to the increasing criticism of and restraints on doctors' powers. Much of this criticism came from the women's movement, which began by attacking the treatment women received in the privacy of the doctor's office, expanded into providing alternative services and demanding female control of medical, and especially reproductive, matters, moved on to defend the system against cutbacks, and has begun to link these concerns, relating them to the political economy. These criticisms helped undermine doctors' absolute authority and thus helped nurses stake their claims.

Women's Health-Care Work / 31

New Signs of Revolt The struggle for medical dominance and the establishment of state health care were central in creating a system that too often served to lock nurses into a subordinate place within an increasingly complex, hierarchical structure. But these two processes themselves must be understood within the context of a dominant ideology that defined women as inferior creatures subject to the whims of their bodies and of a political economy that often helped make this the case by denying women access to the means of controlling their bodies and achieving independence in other ways. From the 1960s on, however, there were visible signs of significant changes in women's conditions and of women's rebellion. All structures and practices, including health-care, were called into question. Many nurses were part of this challenge, and those who were not could not escape its impact, as the women's movement sought to transform women's place in and out of health-care. Undoubtedly, the state funding of a hospital-based delivery system and fee-for-service medical care, as well as the legitimation of an allopathic approach to diagnosis and treatment, has helped equalize the distribution of health services and has contributed to women's improving health and increasing longevity. Some state regulation of the pharmaceutical industry has limited unscrupulous dealings; some state support for the poor, especially the elderly poor, has helped many women survive. These same processes, however, themselves more often the result of power struggles than scientifically established benefits, have also helped create the conditions for women's rebellion against the healthcare system. Women have never passively accepted the conditions of their health, treatment, or regulation. Individually and collectively, they have struggled to alter, avoid, or provide alternatives to the nature and conditions of health-care provision.68 Since the 1960s, such opposition has become particularly evident and more obviously directed against the state system that had grown enormously in size and complexity. Throughout most of this century, doctors controlled not only contraception but also birth. The state prohibited abortion or even the distribution of information on birth control. Women never passively accepted these conditions. However, as women began to stay longer in school and more permanently in the labour force, they increasingly sought additional means to delay and limit pregnancy and to alter the conditions of childbirth. Flouting the legislation, in 1968 a group of students at McGill published the Birth Control Handbook,69 which turned out to be extraordinarily popular and became a very visible example of women's efforts to control their bodies. Indeed, the struggle for greater

32 I Vital Signs

reproductive freedom brought women together in various parts of the country, and discussions moved from issues of contraception to more general questions about shared knowledge and control. More conscious about choosing to give birth and facing fewer pregnancies, women also became more vocal about the hospitalized and managed experience of childbirth. The seemingly personal questions of birth and birth control were linked with the more obviously public issues of health care and power. "In the fall of 1971, a group of young women met to discuss their own health care needs and their dissatisfaction with the healthcare system/'70 By 1973, this small self-help group had joined with others operating an abortion referral system, trained themselves in alternative techniques, and formed the Vancouver Women's Health Collective to provide "health education and preventative care for women."71 Their "Women's Health Booklet"72 was both a catalyst for and a reflection of a challenge to doctors' authority and the structure of state care. Selfhelp clinics began to appear. Mid wives increasingly participated in childbirth, sometimes even in home births. Some alternative strategies have been funded or accepted by the state. Although self-help clinics and other sources of information did increase women's individual control over their personal lives, they also often had the contradictory effect of "accentuating the individual responsibility for one's own health"73 while offering only a limited challenge to the dominant structure. Indeed, they may have served to divert some of the attack on that structure. Funding was usually low and therefore much of the health-care or research work was done by unpaid or underpaid workers, most of them female. It was also frequently short-term and variable, and therefore alternative projects had a somewhat precarious existence. Much of the workers' energy was directed towards applying for grants, and many of the projects were modified to conform to state requirements. The emphasis on self-care and prevention was increasingly lauded by the state. Explicitly, in the 1974 A New Perspective on the Health of Canadians,74 the Federal government sought to legitimate limits on services by calling on individuals to participate in preventing and taking personal responsibility for their own illnesses. Stressing the "decisions by individuals which have repercussions on their health," the document blamed individuals for "behaviour and living habits which adversely affect health."75 Similarly, Statistics Canada's Perspectives on Health76 listed tobacco, alcohol, activity and fitness, drugs "used illegally, taken in certain combinations or mixed with alcohol," accidents in traffic and from "lifestyles," and preventive health practices—namely immunization, Pap smears,

Women's Health-Care Work / 33 and breast self-examination—as "determinants of health status." Although this study does caution that drugs "such as birth control pills, while useful, may have side effects as associated health risks/'77 the point here too is that individual choice and responsibility, not doctors' treatment, pharmaceutical companies' strategies, poverty, working conditions, or public health measures are seen as the causes of illness. Statistics Canada's Canadian Women: Profile of their Health™ does add that "one health researcher" questioned the emphasis on the individual, and it suggests a link between low education levels and bad habits. But it also focuses on individual lifestyle, "alcohol, and drug consumption, levels of smoking and physical activity," without connecting these to working conditions or the health-care system. The ideology of self-help has too often been used to save money and legitimate individual responsibility, while leaving other factors contributing to health untouched. Blamed for their own illnesses, women are also held responsible for the health practices of their families, and are exhorted to reduce cholesterol and salt and increase fibre and calcium—not to mention broccoli—when planning the family meal. It is what could be called an "eat bran, quit smoking, and wear a condom" approach to health and care. It is not only clinic and alternative information sources that have received some state support. Demands for the licensing and funding of midwives, for the shortening of hospital stays for childbirth, and for the movement of babies into mothers' rooms are falling on increasingly sympathetic ears, in large measure because they, too, reduce costs. Doctors have been less enthusiastic than have administrators and other health decision-makers, because these practices often undermine doctors' control. However, reducing the deficit is now a priority in the social service field, and doctors' strength is diminishing as a result. Undoubtedly such developments increase women's control and improve the experience of childbirth for many women. But if these practices become the norm, they may serve to disadvantage women who have little support and many responsibilities at home and therefore need publicly funded rest and care in a hospital. They may also reinforce the notion that birth is simply a brief medical procedure, subject to precisely controlled and prescribed procedures. And they may serve to increase nurses' workload and change the conditions of their work. Increasingly, state commissions and reports have also been supporting a return of care to the community and a decentralization of some care responsibilities and decision-making. For example, in its consultation document on long-term care,79 the Ontario government announced a commitment to directing more resources to providing services in people's home and "calls for increased involvement of the community in

34 / Vital Signs

the new system of long-term care/'80 Similarly, the British Columbia Royal Commission on Health Care and Costs81 maintained that "it is better for long term care residents to live in a less than perfect facility within their own community/7 It also suggested that the province be divided into health regions and each region have a "manager recruited for managerial skill and experience, not necessarily for experience within the health-care system/'82 Such policies could provide more resources and power to the women already providing much of the care, who are being increasingly referred to as "the community/' But given that these policies are suggested in response to financial pressures, it seems likely that women will do more of the health-care work without pay, work now done for pay by women in the health-care system. And the participation in decision-making may be so constrained by managerial decisions and efficiency criteria that women may merely find themselves complicit in the intensification of their labour, in helping others to design systems which mean they work harder. There has been little evidence so far of real transfers of either power or resources to the women who constitute "the community." These provincial and federal reports have also begun to pay heed to the evidence which demonstrates that maintaining health involves much more than personal health practices. For example, Nurturing Health,83 a report from Ontario's Premier's Council on Health Strategy, refers to the "growing body of national and international research [that] has identified a long list of important factors in the social environment that influence the health status of individuals." It concludes that "a healthful lifestyle is not just a matter of individual choice"; rather, it includes such factors as "early childhood experience, hierarchical positions at work; workplace hazards; family and friendship supports; employment status; and environment factors." Again, this stance recognizes many arguments women have long been making about health and could provide a basis for important changes. It could also, however, provide an excuse for limiting resources for health-care services and for cutting back on paid health-care jobs while failing to address the factors identified as central to good health. Indeed, there is little evidence to suggest that states are addressing workplace hazards and employment status questions and plenty of evidence that services are being reduced or abandoned. Moreover, this shift in emphasis often means that little real change takes place in existing services. There is simply less of the same. The state remains a contested terrain, simultaneously contributing to women's liberation and subordination. While the laws, institutions, and funds of the state have served to subordinate women as patients

Women's Health-Care Work / 35

and to denigrate their knowledge, they have also created conditions that encourage and allow women to resist. In the early 1960s, women focused their efforts on reproductive issues, often turning to what was seen as a neutral state for support. These struggles have led to some victories, to some alternative services, to a broadening of the issues in a way that includes all aspects of women's health, and to a recognition that the state is more often on the side of men seeking profit than of women seeking health. At the same time, however, these new strategies "run the risk of reproducing the problems they were intended to overcome. To the extent that there are changes which have only occurred at the periphery of the health-care system, they merely reflect more sophisticated gatekeeping to deny, dismiss or distort the experiences and needs of women."84 Moreover, they often mean more work for nurses, without compensation in terms of money or control. The Conditions and Relations of Women's Health-Care Work That health-care jobs appeared in the public rather than the private sector had particular consequences for the nature and conditions of women's work. At first, these state jobs created possibilities for significant improvements. More recently, their location in the state sector has frequently served to limit women's struggle for change. Hospitals based on an engineering model of the body permitted the specialization and fragmentation of tasks. At the same time, however, they brought nurses together in large institutions where they shared similar experiences. One result was the creation of a wide range of hierarchically organized women's jobs, characterized by limited mobility, vast differences in power and pay, and male dominance. Another was the formation of nurses' unions. Similarly, the demands that the women's movement placed on the state both helped nurses challenge authority structures and altered their working conditions. State employment has thus had and continues to have contradictory effects on women as workers in the healthcare field. In 1941, 90,000 people were counted as working in the Canadian health-services industry; 70 per cent of them were women. By 1961, the numbers had more than tripled, with 281,000 employed in these fields.85 Women increased their share of the work, capturing 73 per cent of the jobs. During the same period, women's overall labour-force participation grew from 21 to 30 per cent. For women, however, this growth did not primarily mean more room at the top or more respect for women's work. State-legitimated quotas, class biases in the education system, and the dominant ideology combined to limit the number of women trained as physicians and surgeons. The proportion of doctors who were

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female did increase between 1941 and 1961, from 4 per cent to a mere 7 per cent. During the same period, more than twice as many men became nurses as women became doctors. And nursing remained undervalued, women's work. Throughout this twenty-year period of rapid growth, nurses remained by far the largest single occupational category within the health-care industry. But the largest growth in the years immediately following the introduction of federal grants for hospital construction and insurance was not in the proportion of either doctors or nurses. In relative terms, the number of technical, professional, clerical, and non-professional service workers increased more. There were three times as many female medical and dental technicians in 1961 as there had been in 1951, compared to twice as many nurses.86 The engineering model, which viewed the body as a group of linked but separate parts, encouraged this fragmentation and specialization of tasks. With this approach, each body part and each aspect of treatment could be dealt with by a different person trained for a specific task rather than for overall care. The nature of the technology developed also reflected this approach, reinforcing the detailed division of labour as some women took blood and others tested it, some flossed and others X-rayed your teeth. While many of these jobs required new skills, they also required fewer years of formal education than nursing, medicine, or dentistry because the workers performed a more limited range of tasks and had a more restricted range of formal responsibility. Their responsibility and power were circumscribed not only as a result of specialized training or technology, however. These and other "para-medical" occupations were "so to speak, 'born' under medical control."87 They were developed largely under conditions set by doctors in a manner designed to maintain medical dominance and to restrict others' areas of competence. The number of nursing aides and assistants also grew rapidly in the postwar period. Graduate female nurses outnumbered women working as assistants and aides by more than three to one in 1941. Twenty years later, there were five nursing aides or assistants for every six graduate nurses.88 Aspects of nursing tasks that were defined as less skilled were separated out and assigned to lower-paid female workers. Although expected to carry out a wider range of tasks than technicians, aides and assistants were given more limited formal training than nurses and placed under the authority of nurses as well as doctors. Indeed, each new fragment resulted in occupations with different training, different pay, different authority, and different conditions of work, creating a hierarchical system which locked women into specif-

Women's Health-Care Work / 37

ic jobs. To move from one position to another almost always required additional training outside the system. In his study of a major metropolitan hospital, Torrance89 found that "to a large extent, the different departments constitute separate worlds where the workers remained as long as they stayed in the hospital/' While increasing the power of many nurses over other workers, the structure decreased the strength of women overall because their different conditions, different education, different credentials, and different pay pitted women against each other. Each new occupation sought to increase its power and prestige by imitating the doctors' professional claims. This meant certification for specific categories and restricting entry to those with particular kinds of education. But these occupations had very limited success, primarily because they failed to understand that doctors' power and respect did not come mainly from their credentials and because doctors worked hard to maintain their own dominance. The strategy of seeking professional power through credentials not only failed to significantly increase their power; it also frequently served to prevent women from uniting with each other to challenge the closed, hierarchical system. Indeed, this strategy reinforced the inequities within the system. As one American study90 concluded, "The very cohesiveness and solidarity with members of one's occupation or specialty, which credentialing mechanisms create and enhance, also runs counter to unification and solidarity among health care workers across occupational lines." These antagonisms were exacerbated by race and class differences. Immigrant women were frequently hired for aide, assistant, and technician positions, while white, Canadian-born, increasingly middle-class women captured most of the nursing jobs. Doctors' power extended throughout the system and the proliferation of specialized jobs served initially to strengthen that power, as well as to save money. State funding promoted hospital expansion and encouraged hospital use and the rationalization of services. The growth in specialties, in technologies, in patient numbers, and in urban concentration also encouraged a centralization of services. All these processes increased the administrative and paper work. More and more women were hired to do clerical work. At the same time, other non-medical services provided more jobs for women, as work in the laundry, in the kitchens and on the floors was extended to accommodate the additional workers and patients. Here, too, recent immigrants from a variety of countries provided a high proportion of the labour force. Very few of these workers "enjoyed any internal mobility, even between jobs at the same level in

38 / Vital Signs other departments/7 and substantial differences in pay, power and other rewards created major divisions.91 Working in the non-profit state sector had advantages for many women during this period. The rapid infusion of state funds meant a shortage of medical personnel. Although the problem was partially solved by dividing up the work into fragments and quickly training women for the jobs, the demand for women workers continued to grow. The rationalization and centralization of health services created large impersonal bureaucracies which brought women together under conditions which invited and allowed resistance. In such massive bureaucratic organizations dedicated more to efficiency than to care, it was more difficult to use old ideologies concerning dedication to public good as a basis for ensuring women's compliance. Moreover, within these large establishments, each occupational category had sufficient numbers to form a power base of its own. Economic conditions, the women's movement, and the relaxation of restrictions on the employment of married women— itself a reflection of shortage—encouraged women to stay longer in the health-care system and thus gave them a greater impetus to demand change.92 Frustrated by the limited success of the professional strategy and facing a lifetime career in health-care work, many women organized and joined unions dedicated to improving their conditions and relations at work. Passive resistance, evident in the declining numbers of women entering the tightly supervised hospital training schools, was a major factor in transferring preparation to community colleges93. This move in turn spelled greater freedom from obedience training and from the constant surveillance in hospital residences. It also meant greater exposure to alternative ideas. The state was concerned about legitimacy and faced with an electorate which strongly supported health-care. It could not relocate in search of cheaper and more compliant labour. It therefore gave in to demands, in some jurisdictions, for the right to strike and in most, for better pay and conditions. In 1946, nurses in Quebec were paid between $10 and $20 for a 54-hour week and had no paid vacation, maternity leave, or pension. Twenty years later, salaries ranged from $85 to $109 for a 36.25-hour work week, and nurses were eligible for four weeks' paid vacation, maternity leave, and pension.94 The 1964 version of Women at Work in Canada95 noted "a considerable improvement in the incomes of nurses" since 1956 and attributed this, along with the similarity in nursing wages across the country, "to shortages of nurses in many areas, to the mobility of a substantial proportion of the nursing profession, as well as to the considerable influence of the registered nurses' associa-

Women's Health-Care Work / 39

tions."96 Collective organizing not only gave women more money and benefits; it also gave them more power to resist arbitrary orders from doctors or other managers. But other women workers were not equally successful. Those with the least recognized skills and the least formal training, who were more readily replaced, often encountered more difficulty in organizing and in having their demands met. Clerical and non-medical service workers were also the ones least able to resist the application of managerial techniques developed in the private, profit-making sector. These workers often moved freely between the state and private sector, were trained and managed by people from the private sector, and frequently used the same technology in both sectors—technology designed to intensify work and control workers. When economic boom turned into economic bust during the 1970s while hospital expenditures continued to rise, the state looked first to those areas with jobs analogous to the private sector as places to apply money-saving strategies. Micro-computers were introduced to reduce and deskill female clerical work; laundry machines replaced female laundry workers; fewer female cleaners used more equipment, had heavier workloads, did "cycle" cleaning, and were replaced on weekends by students paid minimum wage; kitchens were reorganized as assembly lines with fast food techniques. Because medical personnel are engaged in labour-intensive human-service work that is more difficult to mechanize and because their training and professionalism provide them with some control, many of those directly providing health care initially escaped cost-cutting measures. But state cutbacks, along with growing union strength, have encouraged the development of techniques to control and intensify the labour for these women as well. Struggling to maintain their jobs and their hard-won conditions, women are pitted against each other. Antagonisms are reinforced by wide gaps in pay, training, and control. With apparently empty government coffers, pressure from the private sector, and improved conditions for healthcare employees, the state has moved to discipline workers as well as cut costs. Strikes save money for the state, because workers are not paid. But there is no loss of sales as there is in the private sector. Moreover, strikes can be used to legitimate the state by labelling workers as greedy, irresponsible and selfish. At the same time, essential services can be maintained through state orders. The continuing crisis has allowed and encouraged the state to collapse its accumulation and legitimation functions; that is, to justify everything in terms of cost. In the process, state direction of health care has expanded through the imposition of cutbacks and increasing administrative control over

40 / Vital Signs what was already becoming a more and more centralized and rationalized system. Between 1981 and 1982, the number of full-time nurses declined while the number of full-time health-care executives grew.97 The presence of these executives has reduced the power of all medical personnel, as financial, technocratic and bureaucratic considerations take priority over medical and social ones. Doctors no longer solely determine patients' stays; staff no longer are allocated exclusively on the basis of doctors' needs; technology is not purchased exclusively as a result of doctors' arguments. Women patients and women workers have played an important role in demystifying and eroding doctors' unquestioned power, and now administrators are taking up the task for other reasons. It is ironic that doctors are losing control just as more and more women enter medicine.98 The state is also taking up women's call for greater community control and decentralization of functions. But, as with the decline in medical dominance, this will not necessarily mean greater power for women. Decentralization of functions and community control often leave the major decisions about funds in central hands and often establish efficiency as the major criterion for care. New technologies make it possible to maintain control at higher levels while redistributing responsibility for tasks to the local level. After World War II, a combination of factors meant that the state provided many women with relatively good, secure employment in the health-care field, where many gained satisfaction from providing a humanitarian service. Since the mid-1970s, however, there has been little significant improvement. In recent years, conditions have deteriorated. Several studies99 have indicated that nurses leaving nursing complained of "an inability to deliver quality patient care (a consequence of fiscal restraint and staffing reductions), hours of work (the necessity of weekend and shift work), insufficient involvement in the decision making process, salary levels inadequate to compensate for working conditions, and familial responsibilities." Cutbacks have meant an intensification of labour, a reduction in jobs, and a disciplining of workers, making it increasingly difficult to provide a useful service and feel good about the work. This new work organization in large hospitals also made "foreign labour more attractive as a cheaply trained workforce which can be disciplined through both management practices and immigrant regulation. Thus, for example, controls may be implemented to restrict immigration from third world nations by undervaluing ...credentials," but jobs are still offered to the women who immigrate, albeit on the employers' terms.100 More and more work is done by unpaid female volunteers in the market and

Women's Health-Care Work / 41

by unpaid female conscripts in the home, as a solution to the economic crisis is sought in removing women and services from the paid labour force. There are real limits to these strategies however. Many women want and need paid employment. Many of these health services were never provided in the home and, in any case, there are fewer women in the home to do the work. Many women are resisting and will continue to do so. Nursing Work Today Recent developments in nursing work, then, must be understood within the context of changes in the political economy, of changes in other health-care work, of the assumptions built into the system, of the emergence of the women's movement, and of nurses' efforts to shape their conditions of work. The success and extent of state strategies to control both costs and workers have varied from jurisdiction to jurisdiction and with the size of the health-care organization. Yet there are clear general patterns to nursing work. That nurses are treated as women and therefore have a low value attached to their work is evident from the first day they enter a nursing program. Many nurses today hold a diploma in nursing from a college or independent school. An increasing number have taken university undergraduate programs and some have gone on to take graduate degrees. Unlike other apprentices, student nurses are not paid while they learn, although they provide some free labour and incur considerable expenses. Randy Montgomery,101 in a brief to the Ontario Pay Equity Commission, contrasted his experience as an apprentice in male-dominated occupations with the experience of student nurses. In the first year, student nurses spend two days a week in the hospital, pay for "their own uniform, gas, lunch, parking, books, stationery and spend three days in class/' "It costs approximately $3,000" and a "first year nurse is given some responsibility in the hospital but mostly all dirty jobs that the RN doesn't like doing." The nurses who go to university, rather than college, have an extra year of study to pay for before they are paid for their work. When nurses graduate, they are frequently paid less than garbage collectors. Responding to a management consultant who claimed that garbage collectors deserved higher pay because of their working conditions, a nurse responded that "garbage collectors pick up only wrapped refuse, do not work weekends or holidays, or in very bad weather. They don't require a university education. They are not exposed to AIDS, hepatitis or other communicable diseases, they do not have to lift

42 / Vital Signs

weights equivalent to those of a human being nor do they have to dispose of waste as objectionable as faeces or human vomit. In terms of job responsibility, garbage collectors aren't likely to kill someone if they make a mistake. Nor do they have to calculate dosages or in many other ways use their brains and judgement/'102 The precise duties and conditions of the 236,993 nurses registered in Canada in 1986 vary with the size and nature of the health-care service in which they work,103 but there are many common characteristics in the work done by the 89 per cent of them who work as nurses. Each provincial organization that registers nurses has its own particular definition of functions, but they are all similar to the following description set out by the Ontario College of Nurses:104 The Registered Nurse performs acts requiring substantial specialized knowledge, skill, and judgement, both in assessing health needs, and in planning, implementing and evaluating nursing care. These acts include health education, promotion and maintenance of health, prevention of illness or injury, early case-findings, rehabilitation, and implementation of the prescribed medical regime. These acts are supportive and restorative to the health and well-being of individuals, families and communities and are performed either independently or in cooperation with other members of the health team.

As extensive as this definition is, it fails to capture many aspects of nurses' work. Like much of women's work, nursing involves complex, overlapping, and multilevel skills that are frequently invisible to those not doing the work. Nurses are always doing caring work, whatever the other specific tasks the job of the moment requires. They are frequently called on to employ a number of skills simultaneously, and they often have to switch back and forth between complex and simple tasks, between communicating with highly educated personnel and with very young or mentally handicapped patients. They usually have to cooperate with a team, but they are also expected to take orders from above and to give orders to those below them in the hierarchy. They have a great deal of responsibility, but little authority. As one nurse explained, "Within the broad spectrum of the nursing profession there are independent, interdependent as well as dependent functions which influence the means by which nursing must deliver care. By virtue of this unique and complex role, nurses must work collaboratively inside an extremely complex, multi-faceted health-care system."105 Furthermore, as an expert on nursing work explained when testifying before the Ontario Pay Equity Tribunal,106 "Basically, nurses assist people to meet their own needs if they can; and if they cannot

Women's Health-Care Work / 43

meet them at that time, nurses formulate a plan of action through which those needs can be met. Then nurses implement that plan and evaluate the effects of it; and in light of that evaluation, either continue implementing the plan or modify it. That process... is on-going, concurrent, and so it's continuous, and the reason of course is because of the dynamic dimension. Things are always changing; therefore things need to be updated constantly." Although some nurses have become clinical specialists and although all nurses are constantly updating their skills, there are few opportunities for advancement within the system, and the overwhelming majority of nurses do general duty or staff work. Nurses "whose highest education in nursing is either at the baccalaureate or post-basic level have the greatest success in attaining advanced nursing positions," but a significant number of those with graduate degrees continue to do general duty work.107 Some nurses work in educational institutions, where there are more possibilities for promotion. Almost 7 per cent work in nursing homes or homes for the aged, where they have a very good chance of becoming directors—although even if they do, most will continue to do general duty work. But three-quarters of the nurses work in hospitals, most of them in large urban centres, where the places at the top are few and where conditions have been changing significantly.108 To point out that there are few possibilities for promotion is not to suggest that there should be an even more complicated hierarchy within the hospitals or to suggest that some nurses should be seen as more valuable than others. Indeed, general duty work is just as skilled, responsible, and difficult as work in surgical intensive care or obstetrics. Rather, it is to suggest that, unlike workers in many other jobs, nurses cannot view their present conditions as temporary or as a short stop on the way to other work nearer the top. Management styles more appropriate for other workplaces may therefore be inappropriate for nursing work. In large urban hospitals, administrators have been able to introduce management techniques developed to control workers in the corporate world. In Quebec, the engineering model of the body has allowed a scientific management analysis of nursing work which counts the time required to perform each operation defined as a nursing task; nurses' overall time is then allocated on this basis.109 Describing to the Ontario Pay Equity Tribunal the limits of such approaches, the Principal Nursing Officer for Canada110 explained that some estimate it takes six or seven minutes to shower a patient,

44 / Vital Signs but the patient happens to have a heart attack or maybe has had a stroke or maybe has arthritis or something and doesn't move as quickly in and out of the bed as you or I might. I have to help the person, get him into a chair, hope and pray that nobody else is in the shower at the time and I don't have to wait. Get him in, get him washed and dried or whatever, get him dressed, back in the chair, back up to the bed. And somehow the bed gets made, either I do it or somebody else does it. Probably I do it. And it has been alleged that that kind of thing, for example, could be done in six minutes and I have seen areas where those estimates are made. Well, I suggest that even the Holy Ghost couldn't do it in six minutes unless you lifted the patient out, put him in a chair, hosed him down, let him drip dry and then put him back in.

More and more major hospitals have developed a task-based formula for determining the number of nurses required on any shift and for each patient. With the help of the new microelectronic technology, administrators can quickly determine the minimum number of nurses needed in any area at a particular time and can just as quickly develop new work assignments for any nurses considered to be underemployed in particular areas. Nurses themselves provide much of the necessary data as they fill in their patient reports. This precise allocation of nursing time is made possible by the increasing number of nurses who work part-time and who can be easily assigned to different areas. Similarly, by making more and more full-time nurses floaters who are assigned each shift to the area of the hospital with the greatest need, administrators can ensure that there is no slack in the system. Gone are the days when nurses could relax their pace because fewer babies were born last night. Fewer babies now mean fewer nurses and at least the same workload. The increasing use of twelve-hour shifts also means fewer shifts and fewer nurses. At the same time, administrators have sought to cut costs and increase control over workers by developing formulas to determine the minimum number of tasks required for each patient and the minimum number of treatment days. Many operations that formerly involved lengthy hospital stays are now done on an outpatient basis. Women in the obstetrics ward are regularly sent home after twenty-four hours rather than staying the four or five days that were customary a decade ago. As a result, hospital patients stay for only the most severe period of their illness, and each of them requires considerable care. In the very recent past, much of the recovery happened under the nurses' care. New developments in technology have permitted increased monitoring of patients and have expanded the number of machines nurses

Women's Health-Care Work / 45

must use every day. New treatments, combined with the increasing severity of patients' illnesses, have also served to increase the number of things that nurses must do to patients. Current licensing regulations mean that many of these procedures can only be done by nurses or doctors. Constrained by these regulations, many hospital administrators have chosen to abandon their earlier strategy of delegating more of the nursing work to those with more limited training and lower wages. Instead, they have reduced the number of non-nursing staff, expecting nurses to fill the gap. You can ask a nurse to make a bed or clean up vomit, but you cannot ask an aide or an orderly to give needles or hook up IVs. "In recent years, the number of persons employed in Canadian public hospitals as nursing assistants and orderlies remained approximately stable, while their total paid hours of work generally declined....These two measures for nurses alone have increased steadily/'111 Cutbacks in other staff and the increasing demand for the information necessary to monitor workers as well as patients also mean that nurses have less time to devote to patient care. Nurses interviewed by Goldfarb112 for the Ontario Nurses Association indicated that they spent "an average of almost 30 per cent of their time on non-nursing tasks/7 At the same time, cutbacks in capital and operating expenses mean that nurses spend more time soothing patients angry about waiting in halls and more time searching for equipment and materials. The nurses in a major Metropolitan hospital in Quebec113 told of trading sheets for hospital gowns and of running to other floors for much-needed syringes. Moreover, because of the demand to keep close tabs on spending, nurse spend a great deal of time keeping records. On the basis of her hospital study, Campbell114 concluded that "nurses have become professionally responsible for implementing budget cuts/' Such shortages and accounting demands result in more tension, greater surveillance of nurses, and less time for patient care. In a Labour Canada study,115 more than one-third of the staff reported that symptoms specifically related to stressful working conditions had increased for nurses. Combined, these management strategies mean that each nurse has to work harder, each nurse has to perform tasks at many levels, and each nurse's work is more carefully monitored. With the emphasis on measurable and visible tasks, there is little room for the caring work that is the focus of nursing education and the reason why most women enter nursing. As a nurse interviewed for the above-noted study of a major metropolitan hospital116 explained, "You don't have time to talk to patients. Your work is much more compartmentalized. You do this and then you do that and then you do that." "Work has triplicated," said another. Nursing is fragmented into a series of discrete tasks; the

46 / Vital Signs work involves "doing more things to people, not for people/' "more machine tending than caring for people/7 The satisfaction that came from knowing that you helped someone get better disappears when they stay for such a short period, when they are so ill and when they have to have so much done for them in so short a period of time. Although new technologies and new methods of organizing work have significantly increased nurses7 responsibilities and workloads, they have not significantly increased nurses' power. Nurses remain subordinate to doctors. Doctors' authority is justified on the basis of their responsibility for patients and their superior knowledge. Yet nurses are held accountable, in spite of having little control over patient care or their own working conditions. The most blatant example of this combination of blame and lack of authority is the Grange Commission investigation of baby deaths at the Hospital for Sick Children in Toronto. In this inquiry, nurses alone were interrogated about their performance, even though it was nurses who first suggested that low staff ratios and the limited time spent by high-risk children in intensive care were endangering lives. Nurses were the prime suspects despite the fact that they were the first to draw attention to the alarming rise in baby deaths and that they have little control over diagnosis, treatment, or the total amount of care available.117 Moreover, nurses now have more formal training than doctors in some matters and may in fact do most of the work, although they are still very much under the doctors' authority. As one nurse explained,118 she has more courses in nutrition than the doctor and frequently must make quick decisions about what patients can eat, but she has to have a doctor's permission to change a patient's diet prescription. A 1984 Labour Canada study119 found that more than 60 per cent of nursing directors reported that nurses complained about lack of opportunity to make decisions. Nurses in large hospitals were more likely than those in small ones to complain, a not surprising finding given the increasing bureaucratic regulation in hospitals. The study120 concluded that the younger and more highly educated health workers "tend to become dissatisfied with traditional jobs that are production line, highly supervised, or over-specialized, and which lack the important qualities of autonomy, learning, mobility and meaningfulness." This intensification of nursing work, the continuing lack of power, and the increasing surveillance of nurses has happened at the same time as more and more women are staying in the labour force, even after they marry and have children. In the past, nursing was done primarily by young single women before they married or by women who remained single and devoted their Jives to nursing, usually living in a

Women's Health-Care Work / 47

hospital residence where the daily domestic chores were done by others. Indeed, much of the nursing work was done by nurses-in-training, and married women were not allowed to keep their nursing jobs. Those who made a career of nursing often rose to senior nursing positions. In other words, few women stayed in this very demanding job for life. And those who did tended to have other kinds of support and some power. By 1986, however, there was a significantly different nursing work force. The student nurses were gone from the hospital residences. "Of the registered nurses employed in nursing in 1986, fully 93 percent were employed in direct patient care/'121 More than 40 per cent of the registered nurses were over 40 years of age, and more than 70 per cent of the registered nurses were married.122 Today, many nurses have two jobs: one at home and one in the labour force. An increasingly heavy nursing workload would be difficult for anyone to handle, particularly given the stressful nature of nursing even in good times. It is especially difficult for women with another job at home and for women who spend all day or night in demanding patient care. It is not surprising that nurses in the Goldfarb123 study offered burnout or exhaustion as a key reason for leaving nursing. This is not to argue that it is primarily family responsibilities that count for women. "Friss notes that one of the prevailing beliefs of practicing managers is that turnover is inevitable because its causes are tied to the delinquency of workers or the home-career conflicts of female employees in the health care system/'124 Yet Howard Smith125 found in his study of American hospital workers that the "personal characteristics of employees did not manifest any fruitful results for predicting job satisfaction, which suggests that job satisfaction results from the nature of the organizational climate/' Carol Weisman, Cheryl Alexander, and Gary Chase126 report on a study which concludes that "75 percent of the 'contemplated turnover' may be attributed to job rather than family reasons," and their own research confirms these findings. The Goldfarb127 study done for the Ontario Nurses Association also demonstrated that the major cause of nursing turnover is working conditions in the healthcare industry, not women's family responsibilities. Many nurses have responded to these changing conditions and relations by leaving nursing altogether, by moving to registry services, or by working part-time. A study by Employment and Immigration Canada128 "suggests an occupation withdrawal rate which is high relative to other professional categories." In Goldfarb's129 survey, as many as one in seven nurses indicated that they intended to leave nursing. And the number of nurses employed part-time has been steadily increas-

48 I Vital Signs

ing. "Approximately 37 per cent of nurses were employed part-time in 1986 compared to 35 in 1980 and 30 per cent in 1970."130 Women's reasons for leaving the profession or for working part-time are very similar. They blame burnout and exhaustion, shift work and long hours, a heavy workload, understaffing, low pay and lack of power.131 Research in the United States132 found that "the single most important factor identified by agency employed nurses as determining their choice of employment was control over working conditions." While the move to part-time work gives both the hospital and the nurses more flexibility, it also creates problems for nurses. When nurses work part-time or with a registry, they seldom follow patients through their hospital stay. Consequently, these nurses in particular find it difficult to feel they are helping any individual get better. Nurses request temporary assignments as a means of controlling their work hours, of escaping close supervision, or of avoiding assignments they hate.133 For many, it is a strategy for coping with two jobs and high work stress. But these nurses are pressured to work very hard in shorter hours and often derive little satisfaction from the care of patients. In addition, workers who travel from ward to ward have few opportunities to develop relationships with other nurses. They often eat lunch and take coffee breaks alone. They seldom gain the support and stimulation that long-term relationships on the job can provide. The increasing use of part-time, registry, and "floating" nurses also has consequences for the nurses assigned full-time to particular wards. The regularly assigned nurses spend more time training and introducing those temporarily assigned to the area, leaving all nurses less time for patient care. Furthermore, it is difficult to develop teamwork and group morale when the work force is constantly changing. In this situation, nurses share less and have fewer opportunities to get together to organize for change. These management strategies to reduce costs and increase control are easiest to implement in large, urban hospitals. This probably explains why the Goldfarb134 survey found that nurses in Toronto were the least satisfied and those in small communities the most satisfied, and why Labour Canada found that the complaints about lack of opportunity to make decisions increased with the size of the city. In both small and large communities, however, managements have used other strategies in non-hospital settings for similar purposes. In nursing homes and homes for the aged, for example, management has relied on the older techniques of fragmenting the work and allocating most of the job to lower-paid workers. Fewer direct medical treatments are done in these other health-care institutions. Often a lone nurse does

Women s Health-Care Work / 49

the needles and the pills while nurse's aides and health-care aides do the bulk of the caring work. Nurses in these institutions frequently have very heavy responsibilities and little variety in their work. Based on the finding of the Goldfarb study, the Ontario Nurses Association135 has summed up the current situation: Nurses are required to endure working conditions that greatly reduce the amount of direct quality care they can give to their patients. These conditions include: - too few support staff - excessive patient loads - increasing demands to perform non-nursing duties - poor work scheduling These frustrating conditions, coupled with other working life frustrations—lack of recognition, poor employer support for extra education, little say in health care management—have created a crisis both for Ontario Nurses and its health care system as a whole. Although the ONA confined its conclusions to Ontario, these patterns are evident across Canada.

Conclusions Health and illness, as well as their treatment, are socially constructed. The set of institutions and relations that constitutes the state plays a central role in that social construction. The process is dynamic and contradictory, serving more the interests of profit-making and men than of health and women, but always to some extent structured by women's initiatives and responses. The conditions for health, the distribution of treatment, and the nature of health-care work have significantly improved for women in the postwar years, to a large extent as the result of women's struggles and of state intervention. But conditions for both health and resistance are deteriorating. Women find themselves defending the very system they have been so critical of in the past, raising difficult questions about alternative, and possible, strategies. What is clear is that strategy must begin with a better understanding of the political economy—understood to encompass the household, the formal economy, and the state—and its specific impact on women. It is an enormous project and one barely begun, but a crucial one if women are to define and determine their own health.

50 / Vital Signs NOTES 1.

John A. Price, "Canadian Indian Families/7 in The Canadian family, ed. K. Ishwaran (Toronto: Gage, 1983), 77.

2.

H.H. Loughton, ed., A Gentlewoman in Upper Canada (Toronto: Clarke, Irwin, 1964), 67,157.

3.

Ladies of Toronto and Chief Cities and Towns in Canada, 1877, The Canadian Home Cook Book (Toronto: Hunter, Rose and Company, 1970), 15.

4.

Grandma Nichols, The Great Nineteenth Century Medicine Manual (Toronto: Coles, 1978), unpaginated.

5.

Judi Coburn, "T See and Am Silent': A Short History of Nursing in Ontario, 1850-1930," in Health and Canadian Society, ed. D. Coburn, C. Darcy, G. Torrance, and P. New (Toronto: Fitzhenry and Whiteside, 1981), 183.

6.

Lady Aberdeen, "Achievement of the National Council of Women," in The Proper Sphere, ed. Ramsey Cook and Wendy Mitchinson (Toronto: Oxford University Press, 1976), 204.

7.

Coburn, "'I See and Am Silent'," 130.

8.

M. MacMurchy, "The Woman—Bless Her," in Cook and Mitchinson, The Proper Sphere, 183.

9.

Maria De Konick, Francine Saillant et Lise Dunnigan, Essai sur la sante des femmes (Quebec: Conseil de statut de la femme, 1981), 42, 43.

10. Alison Prentice, Paula Bourne, Gail Cuthbert Brandt, Beth Light, Wendy Mitchinson, and Naomi Black, Canadian Women: A History (Toronto: Harcourt Brace Jovanovich, 1988), 54. 11. Relief Mackay, "Poor Relief and Medicine in Nova Scotia, 1749-1783," in Medicine in Canadian Society, ed. S.E.D. Shortt (Montreal: McGill-Queen's University Press, 1981), 80. 12. For a discussion of public health measures, see Terry Copps, "Public Health in Montreal, 1870-1930," and Neil Sutherland, "To Create a Strong and Healthy Race7: School Children in the Public Health Movement, 1880-1914," in Shortt, Medicine in Canadian Society.

Women's Health-Care Work / 51 13. Barbara Tunis, "Medical Licensing in Lower Canada: The Dispute over Canada's First Medical Degree," in Shortt, Medicine in Canadian Society. 14. David Naylor, Private Practice, Public Payment (Kingston: McGill-Queen's University Press, 1986), 18,19. 15. See George Torrance, "Socio-Historical Overview: The Development of the Canadian Health System," in Coburn et al. Health in Canadian Society. 16. See J.M. Gibbon and M.S. Mathewson, Three Centuries of Canadian Nursing (Toronto: MacMillan, 1947); and Kenneth G. Pryke, "Poor Relief and Health Care in Halifax, 1827-1849," in Essays in the History of Canadian Medicine, ed. Wendy Mitchinson and Janice Dickin McGinnis (Toronto: McClelland and Stewart, 1988). 17. Geoffrey Bilson, "Canadian Doctors and the Cholera," in Shortt, Medicine in Canadian Society, 118. 18. Veronica Strong-Boag, "Canada's Women Doctors: Feminism Constrained," in Shortt, Medicine in Canadian Society, I I I . 19. Ibid, 112. 20. Joyce Leeson and Judith Gray, Women and Medicine (London: Tavistock, 1978) 45. 21. Eva MacDonald and Elizabeth Webb, "A Survey of Women Physicians in Canada, 1882-1964," Canadian Medical Association Journal 94 (June 1966). 22. Dominion Bureau of Statistics, Census of Canada: Labour Force (Ottawa: Queen's Printer, 1966), Table 8A. 23. David Cayley, Doctoring the Family (Montreal: CBC, 1985), 7. 24. Richard Wertz and Dorothy Wertz, Lying In: A History of Chidbirth in America (New York: Schocken, 1979), 39. 25. Cayley, Doctoring the Family, 15. 26. Ibid. 27. Ibid. 28. Susan Buckley, "Ladies or Midwives? Efforts to Reduce Infant and Maternal Mortality," in A Not Unreasonable Claim: Women and Reform in Canada, 1880-1920, ed. Linda Kealey (Toronto: Women's Press, 1979), 136.

52 / Vital Signs 29. Ibid., 137. 30. Naylor, Private Practice, Public Payment, 22. 31. Ann Oakley, Subject Woman (New York: Pantheon, 1981), 189. 32. Thomas McKeown, "Medical Technology and Health Care/' in Doctors, Patients and Society, ed. M.S. Straum and D.E. Larsen (Waterloo: Wilfrid Laurier University Press, 1981), 261. 33. John C. Moskop, 'The Nature and Limits of the Physician's Authority/' in Straum and Larsen, Doctors, Patients and Society, 34. 34. Ruth Cooperstock and Harvey Lennard, "Role Strain and Tranquilizer Use" in Coburn et al., Health and Canadian Society. 35. Anita Direcks and Ellen't Hoen, "DES: The Crime Continues," in Adverse Effects: Women and the Pharmaceutical Industry, ed. Kathleen McDonnell (Toronto: Women's Press, 1986). 36. Michael Rachlis and Carol Kushner, "Under the Knife," The Globe and Mail Report on Business, October 1992, 88. 37. Ibid, 86. 38. Sidney Lee, Quebec's Health System: A Decade of Change, 1967-77 (Montreal: McGill University Press, 1979), 5. 39. National Council of Women of Canada, Women of Canada: Their Life and Work (Ottawa: NCWC, 1975), 77. 40. Published in Beth Light and Ruth Pierson, eds. No Easy Road: Women in Canada, 1920s to 1960s (Toronto: New Hoghouse Press, 1990), 75. 41. See Torrance, "Socio-Historical Overview." 42. Alice Baumgart, "The Nursing Workforce in Canada" in Canadian Nursing Faces the Future: Development and Change, ed. Alice Baumgart and Jenniece Larsen (Toronto: C.V. Mosby, 1988), 42. 43. Helen Mussallam, "The Changing Roles of Professional Nurses' Associations," in Canadian Nursing Faces the Future, ed. Baumgart and Larsen, 401. 44. Nicole de Seve, Diane Lamoureaux et Joelle Levesque, Femmes, infirmieres et si c'etait la meme histoire (Quebec: Mimeo, 1984), 9.

Women's Health-Care Work / 53 45. Quoted in Light and Pierson, No Easy Road, 86. 46. Coburn, "I See and Am Silent/' 47. Jo Ann Whittaker, 'The Search for Legitimacy: Nurses' Registration in British Columbia, 1913-1935," in Not Just Pin Money, ed. Barbara Latham and Roberta Pazdro (Victoria: Camosun College, 1984), 315. 48. See Pat Armstrong and Hugh Armstrong, "Sex and the Professions in Canada," Journal of Canadian Studies 27, no.l (Spring 1992). 49. Gail Young, "A Woman in Medicine: Reflections from the Inside," in Women, Health and Reproduction, ed. H. Roberts (London: Routledge and Kegan Paul, 1981). 50. Leonard Marsh, Report on Social Security for Canada (Toronto: University of Toronto Press, 1975), xxiii, xxiv. 51. See Pat Armstrong and Hugh Armstrong, "Taking Women into Account: Redefining and Intensifying Employment in Canada," in Feminization of the Labour Force, ed. Jane Jensen, Elizabeth Hagen, and Ceallaigh Reddy (Oxford: Polity Press, 1988). 52. Pryke, "Poor Relief and Health Care in Halifax." 53. Lee Soderstrom, The Canadian Health System (London: Croom Helm, 1978), 5. 54. Malcolm Taylor, Health Insurance and Canadian Public Policy (Montreal: McGill-Queen's University Press, 1978), 8. 55. Ibid, 162. 56. See, for example Soderstrom, The Canadian Health System, or Taylor, Health Insurance and Canadian Public Policy. 57. Taylor, Health Insurance and Canadian Public Policy, 235. 58. Canada, Royal Commission on Health Services. Report, Volume 1 (Ottawa: Queen's Printer, 1964), 6. 59. Donald Swartz, "The Politics of Reform: Conflict and Accomodation in Canadian Health Policy," in The Canadian State: Political Economy aand Political Power, ed. Leo Panitch (Toronto: University of Toronto Press, 1977), 323.

54 / Vital Signs 60. Mussallam, 'The Changing Roles of Professional Nurses7 Associations/' 407. 61. Taylor, Health Insurance and Canadian Public Policy, 342. 62. Moskop, 'The Nature and Limits of the Physician's Authority," 35. 63. Philip E. Enterline, J. Corbet McDonald, Alison D. McDonald, Lise Davignon, and Vera Salter, "Effects of 'Free' Medical Care on Medical Practice: The Quebec Experience," The New England Journal of Medicine 288, no.2 (1973). 64. Erica Bates and Helen Lapsley, The Health Machine (Ringwood, Australia: Penguin, 1985), 71. 65. CSN, Choisir (Montreal: Mimeo, n.d.), 43, 47. 66. Taylor, Health Insurance and Canadian Public Policy. 67. See Enterline et al., "Effects of 'Free' Medical Care on Medical Practice"; R.G. Evans, "Economic Perspective," in National Health Insurance: Can the U.S. Learn from Canada? ed. S. Andreopoulos (New York: Wiley, 1975). 68. See, for example, Nancy Kleiber and Linda Light, Caring for Ourselves: An Alternative Structure for Health Care (Vancouver: B.C. Public Health, 1978); Kathleen McDonnell and Mariana Valverde, The Healthsharing Book (Toronto: Women's Press, 1985); Eleanor Wright Pelrine, Morgentaler (Toronto:, 1975); Dorothy Smith and Sara J. David, Women Look at Psychiatry (Vancouver: Press Gang, 1975); Montreal Health Press, Menopause: A Well Woman Book (Montreal: Montreal Health Press, 1990). 69. The publication of this book marked the beginning of what became the Montreal Health Press. 70. Kleiber and Light, Caring for Ourselves, 9. 71. Ibid. 72. Vancouver Women's Health Collective, A Vancouver Women's Health Booklet (Vancouver: Vancouver Women's Health Collective, 1972). 73. Vicente Navarro, "The Crisis of the International Capitalist Order and Its Implications on the Welfare State," in Issues in the Political Economy of Health, ed. J.B. McKinlay (London: Tavistock, 1984), 130.

Women's Health-Care Work / 55 74. Marc Lalonde, A New Perspective on Health of Canadians (Ottawa: Queen's Printer, 1974). 75. Ibid., 34. 76. Janet Abelson, Peter Paddon, and Claude Strohmenger, Perspectives on Health (Ottawa: Statistics Canada, 1983), 35. 77. Ibid. 78. Louise Lapierre, Canadian Women: Profile of Their Health (Ottawa: Statistics Canada, 1984), 15. 79. Ontario, Ministry of Community and Social Services, Ministry of Health, and Ministry of Citizenship, Redirection of Long-Term Care and Support Services in Ontario: A Public Consultation Paper (Toronto: Ministry of Community and Social Services, 1991), 43. 80. Ibid, 6. 81. British Columbia, Royal Commission on Health Care and Costs, Closer to Home (Victoria: Province of British Columbia, 1991), 33. 82. Ibid., 15. 83. Ontario, Premier's Council on Health Strategy, Nurturing Health: A Framework on the Determinants of Health (Toronto: Province of Ontario, 1991), 1. 84. Alice Baumgart, "Address" (Toronto: Mimeo, 1985), 10,11. 85. Dominion Bureau of Statistics, Census of Canada: Labour Force, Tables 12 and 12B. 86. Calculated from ibid. 87. George Torrance, "The Underside of the Hospital: Recruitment and the Meaning of Work Among Non-Professional Hospital Workers/' in The Sociology of Work: Papers in Honour of Oswald Hall, ed. Audrey Wipper (Ottawa: Carleton University Press, 1984), 217. 88. Calculated from Dominion Bureau of Statistics, Census of Canada: Labour Force. 89. George Torrance, "Hospitals as Health Factories/' in Coburn et al. Health and Canadian Society, 491.

56 / Vital Signs 90. Irene Butler, Eugenia Carpenter, Bonnie Kay, and Ruth Simmons, Sex and Status: Hierarchies in the Health Workforce (Michigan: America Public Health Association, 1985) 44, 45. 91. Torrance, "The Underside of the Hospital/' 217. 92. See Pat Armstrong and Hugh Armstrong, The Double Ghetto: Canadian Women and Their Segregated Work (Toronto: McClelland and Stewart, 1984), Chapter 6, for further discussion of factors encouraging women to enter the labour force. 93. H. Rocke Robertson, Health Care in Canada: A Commentary, Background Study for the Science Council of Canada (Ottawa: Department of Labour, 1964), 76. 94. de Seve, Lamoureux et Levesque, Femmes, infirmieres et si c'etait la meme histoire, 26. 95. Canada, Department of Labour, Women at Work in Canada (Ottawa: Department of Labour, 1964), 76. 96. Ibid., 78. 97. Canada, Health and Welfare, Health Personnel in Canada (Ottawa: Health and Welfare, 1988). 98. See Bernard Blishen, Doctors in Canada (Toronto: University of Toronto Press, 1991), Chapter 10, for a summary of the pressure for reduction in physicians' power. 99. Canada, Employment and Immigration Canada, The Labour Market for Nurses in Canada: A Summary Discussion and Analysis (Ottawa: Employment and Immigration Canada, 1989), 12. 100. Terry Wotherspoon, Immigration, Gender and Professional Labour: State Regulation of Nursing and Teaching (Paper presented to the Learned Societies meetings, Vancouver, 1990), 14. 101. Randy Montgomery, "Brief to Pay Equity Commission/' Ontario, March 31,1988,1. 102. Barbara Engelson, Letter to Elenor Ross, President, Registered Nursing Association of Ontario, May 12,1988. 103. Statistics Canada, Nursing in Canada, 1986 (Ottawa: Supply and Services Canada, 1988), 7.

Women's Health-Care Work / 57 104. College of Nurses of Ontario, Standards of Practice for Registered Nurses and Registered Nursing Assistants (Toronto: College of Nurses of Ontario, 1987), 6. 105. Linda Waterhouse, Letter to Barbara Engelson. Ontario Pay Equity Commission files, May 17,1988 106. Testimony of Josephine Flaherty, in Ontario Nurses Association v Women's College Hospital, Sunnybrook Hospital and North York General Hospital, 1991. 107. Employment and Immigration Canada, The Labour Market for Nurses in Canada, 3. 108. Ibid., Table 1. 109. See Lise Marie Audette, Jocelyne Carle, Angeline Simard, Charles Tilquin et collaborateurs, PRN75: Un Systeme d'information quantitative pour la gestion des soins infirmiers (Montreal: CSN, 1970). For a critique of this approach, see Andre Billette avec la collaboration de Guy Frechet et Claude Labbe, L'Infirmiere et la systeme PRN (Quebec: CSN 1982). 110. Josephine Flaherty, Testimony in Ontario Nurses Association v Women's College Hospital, Sunnybrook Hospital and North York Hospital, 1991. 111. Employment and Immigration Canada, The Labour Market for Nurses in Canada, 7. 112. Goldfarb Corporation, The Nursing Shortage in Ontario: A Research Report for the Ontario Nurses Association, March 1988, 52. 113. Interviews conducted for a case study of a major metropolitan hospital in Quebec. The research was directed by Pat Armstrong and Hugh Armstrong and has not yet been published. 114. Marie Campbell, "Management as 'Ruling': A Class Phenomenon in Nursing/' Studies in Political Economy 27 (Autumn 1988), 46. 115. Labour Canada, The Working Environment in Canadian Hospitals: Constraints and Opportunities (Ottawa: Labour Canada, 1984), 28. 116. See note 113. 117. Elaine Buckley Day, "A 20th Century Witch Hunt: A Feminist Critique of the Grange Royal Commission on the Deaths at the Hospital for Sick Children," Studies in Political Economy 24 (Autumn 1987).

58 / Vital Signs 118. See note 113. 119. Labour Canada, The Working Environment in Canadian Hospitals, 17. 120. Ibid, 25 121. Employment and Immigration Canada, The Labour Market for Nurses in Canada, 3. 122. Ibid, 11 123. Goldfarb Corporation, The Nursing Shortage in Ontario, 11. 124. Robert Myrtle and Juan Robertson, "Determinants of Job Satisfaction in Nursing Care Units/7 The Journal of Long-Term Care Administration 7 (Winter 1979), 18. 125. Howard Smith, "Quality of Working Life in a Health Maintenance Organization: Comparisons of Medical And Ancillary Personnel/' Journal of Ambulatory Care Management 3 (November 1980), 45. 126. Carol Weisman, Cheryl Alexander, and Gary Chase, "Job Satisfaction Among Hospital Nurses: A Longitudinal Study/' Health Services Research 15 (Winter 1980), 432. 127. Goldfarb Corporation, The Nursing Shortage in Ontario. 128. Employment and Immigration Canada, The Labour Market for Nurses in Canada, 14. 129. Goldfarb Corporation, The Nursing Shortage in Ontario, 27. 130. Statistics Canada, Nursing in Canada, 7. 131. Goldfarb Corporation, The Nursing Shortage in Ontario, 30. 132. Charles White, "Where Have All the Nurses Gone—and Why? "Hospitals 54 (April 1980), 70. 133. Ibid. 134. Goldfarb Corporation, The Nursing Shortage in Ontario, 62. 135. Ontario Nurses Association, Press Release, 1988.

A Case Study Examination of Nurses and Patient Information Technology Jacqueline A. Choiniere Introduction The work of nurses is increasingly performed in a highly technological environment. On a typical day, a nurse may record patients' temperatures using an electronic thermometer, continuously monitor patients' heart rates and rhythms and blood pressures from the nurses' station, and send and receive information via computer regarding diet changes and test results. In addition, her very presence on a ward for a particular shift may be the result of calculations made using another technology: the patient classification system. These are only a few of the many and varied technologies that are commonplace today in most general hospitals. Understanding what effect technology has on nurses' work requires a particular analytical approach. The technology itself must be examined, but not in isolation. We must also consider why the particular technology was chosen and what effect those introducing the technology intend-

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ed, as well as the ways in which the nurses, as workers, have responded to the technology, with particular reference to questions of skill. In addition, the relationship between these general considerations or factors (why the technology is introduced; the technology itself, and the response of the worker) is complex and at times contradictory. For example, the worker's response to the technology may be to use it in a manner not intended by those who introduced it. This in turn could contribute to the introduction of more or different technologies. Therefore any examination of technological change in the workplace must take all of these complex relations into account. Furthermore, this examination must also consider the fluid nature of these relations. Each factor is, at the same time, a cause and a result of other factors. This type of complex or dialectical relationship means, therefore, that we cannot predict with absolute accuracy, that a particular piece of equipment will have a specific effect. This approach also requires that the technology be examined in the context of the work setting, since this provides an accurate assessment of how nurses have responded to the technology and how it has affected their labour process and skills. It is also essential that the analysis take the larger social context into account, since it also influences technological change at all stages. In view of these methodological considerations, a case study was conducted in a critical care unit, located within a large metropolitan Ontario hospital. The choice of case study method was informed by several concerns. As already discussed, analysing the technology in context is crucial to achieving a full understanding of the impact. The case study method allows for this type of intensive examination and also recognizes that those who do the work are the most expert in describing their labour. In this particular case study, staff nurses were contacted in their workplace, since these individuals and this setting would best provide an examination of all the relevant factors involved in the changes to nurses' work. Two specific patient information technologies—the computerized patient information system and the patient classification system—were examined, with particular focus on why each was implemented, how it was implemented, the technology itself, how nurses had reacted, and whether nurses' skills had been affected and if so, how. This case study is the result of several visits to the critical care unit. Information was compiled through participant observation. (My background as a nurse, and specifically as a former full-time worker within this unit, greatly enhanced the quality of exchanges.) Open-ended interviews with staff nurses were also conducted. The nurses were aware that the interviews were part of a study of technological change.

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The unstructured interview format was chosen in order to discourage artificial barriers between the nurses and myself—a consideration that Oakley and others2 have argued is of particular concern when women are the focus of study. This format also allowed the nurses to clarify their answers by providing more detail and offering examples. Not all social scientists believe that the case study is a valid research instrument. Attewell, for example, in exploring the relationship between method and findings, asserts that results depend on the method used. In his review of research on the relationship between technological change and the skill levels of clerical workers, he notes that studies using a qualitative, case study method are more likely to conclude that deskilling occurs than are investigations that employ a quantitative method.3 In the face of this inconsistency, Attewell firmly aligns himself with the quantitative studies, declaring that qualitative methods are flawed because of their inability to provide a broad comparison of clerical workers. Contrary to Attewell's position, this article argues that quantitative methods often obscure the true experiences of the worker. Studies that employ an extremely wide-angled view may sacrifice important information. Such surveys may fail to detect important contradictions in the labour process— contradictions apparent only to those actually performing the work. Also a larger-scale, quantitative study transforms skill into a one-dimensional concept. Lost is the context of the particular work setting, and as a result the particular nature of skill in that setting may be missed. In other words, although quantitative methods provide a view of many work settings, qualitative methods enable a more detailed and richer analysis of a particular work site. Technology: Why Is It Implemented? As previously discussed, many traditional approaches to the discussion of technology and the reasons for its implementation have been too simplistic. Many debates display either a technological determinist stance or a " passive worker" stance (one that underemphasizes the possibility of worker resistance to the introduction of the technology). Technological determinists contend that the machine is primarily responsible for the conditions of work. Traditional functionalist theories often credit technology itself for any change in the labour process and view the technology as a natural component of rationalization. Missing from this type of analysis is the human factor: who introduced the technology, why they chose that particular technology, and how workers responded. Using the example of computer technology and clerical work, the functionalist paradigm would view the decision to acquire the computer as an inevitable and progressive step. The technology itself is considered to be

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a response to general societal needs, and once it is in place the computer automatically restructures both work and the worker. In contrast to technological determinism are arguments, such as Braverman's, that adopt a " passive worker" stance. Braverman insists tha the conditions of work are more than just a result of the machinery of work. Instead, he argues, the technology or machinery is but a tool which helps to place control of the labour process firmly in capitalist hands. The goal of the capitalist—to seize control from the worker by reorganizing the labour process—assumes primacy. The type of technology is chosen objectively by the capitalist to increase control over workers while increasing their output. As a result, management is able to maximize profits.4 In other words, the technologies are chosen for specific reasons, and cannot be viewed as the automatic result of progress. Braverman asserts that this reorganization of work often includes the application of scientific management techniques. Scientific management, or Taylorism, he argues, includes those technologies that separate the worker from control over his or her labour process. The worker no longer controls the type of work done, how the work is carried out, or the time in which the task must be completed. The assembly line is one such technological application of scientific management.5 Braverman's position is an improvement over technological determinism, but problems remain with his analysis. True, he discusses the motivations of the capitalist as well as the technology itself, and he views the technology as a method of creating particular changes in the labour process. But he assigns an inappropriate amount of unchallenged power to the capitalist and fails to recognize the contradictory impact of the technology: The same technology that decreases worker control may also contribute to the organization of opposition to the technology Braverman deals inadequately with the difficulties faced by the capitalist in implementing Taylorism because his analysis treats workers as passive recipients of these labour process changes and does not credit them with the ability to resist.6 Although there are numerous technologies within the hospital setting, this case study will focus specifically on the computerized patient information system and the patient classification system. These two technologies fit under the general heading of " patient information related technology"; that is, systems and procedures for handling, transforming, and processing patient information. The growth of information-related technologies in hospitals has been one response by administrators to mounting health-care costs. Yalnizyan7 in a comprehensive 1986 study of Ontario hospitals for the Service Employees International Union, uses information provided by hospital

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administrators to predict that purchase of this type of technology would be high priority in the mid- to late 1980s. The state has demanded that hospitals economize in their delivery of care. In response, hospitals have embarked on a program of increased rationalization.8 Important goals in this rationalization process have been to increase the productivity and accountability of various departments. One hospital administrator provides the following endorsement for the computer technology that is believed to aid in achieving these goals. [W]e have true pictures of what gets charged to each department....We could...see what certain doctors are spending on their patients. It's going to be exciting to be an administrator.9

Thus, the technology enables a closer monitoring of care, which in turn sets the stage for increased accountability and, theoretically, for improved productivity. Programs such as " quality assurance" are often linked to patient information technologies, and are touted as necessary safeguards to ensure that good patient care is provided. But these stated goals are suspect. In the hospital studied, the Chairperson of the Quality Assurance Committee possessed training only in business administration; indicating that cost control was at least as important as patient care. There are those who argue that rationalized, standardized care is desirable; that good health care is, and should be, objectively scientific. In other words, there are (or it is possible to develop) acceptable, proven tests and appropriate treatments for each disease, and these should be consistently and identically applied to all, regardless of age, family history, or social or cultural factors. Opposing this engineering model of health care are those who argue that it results in patients being treated like a collection of parts—parts that are identical to those of the rest of the population—rather than as unique, whole individuals. Holistic health care cannot exist in this standardized environment.10 When treatment becomes rationalized or objectified in this manner, it is much easier to monitor. If there is one particular type of treatment required for each disease, then it is easy to assess whether the practitioner is acting " appropriately/' This rationalization of care bears a close resemblance to Taylor's " Scientific Management/' Hospital administrators are better able to promote cost savings by first standardizing treatments and then decreasing the amount of treatment required. Campbell, who has studied information technologies within the hospital setting, argues that these technologies aid in achieving the admin-

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istration's rationalization goals. The information systems provide management with intimate knowledge of the work processes. This, in turn, allows management to move to control those very processes.11 The growth of information technology in the hospital environment must also be understood within the context of a capitalist economy. Manufacturers of computers and related equipment are influential members of this economy. The goal of profit dictates that these technologies be made attractive to potential buyers; thus, promotion of the products includes promises of great savings. Hospital administrators, often educated according to private-sector, competitive principles, and particularly given recent escalating health costs, are very susceptible to these promises. In the hospital studied, the computerized patient information system and the patient classification system, were separate at the time of the study, but the two will eventually be combined into one coordinated patient and staff management system. At present, the patient information system coordinates only a few peripheral activities, such as patient census counts and the communication of lab and dietary changes to the departments concerned. The patient classification system, though not yet computerized, assesses the required care of each patient according to standard treatment practices. But, more important, these standard treatments or procedures have been clustered into care levels according to the amount of time each takes to perform.12 Nursing management has also been pressured into adopting this type of technology in order to justify staffing and administrative budgets to its administrative superiors and to the Ministry of Health. This method of assessing nursing staff needs is a considerable departure from the traditional arrangement that relied on the experience of the head nurse and other staff nurses and that took historical staffing practices into account.13 But there is also evidence that nurse managers consider the new technology an improvement: a more sophisticated and dependable manner of controlling the staffing complements on the hospital wards.14 This stance conveys the belief that the head nurse, or other staff nurses, cannot be trusted to adequately streamline staffing needs. The experience/abilities, and skills of nurses are therefore undermined in favour of this rationalizing system—a system considered to be more trustworthy and superior to years of nursing experience. Implicit in this administrative position is the belief that nursing care can and should be rationalized and routinized. For rationalization to occur within nursing departments, management must ensure that nurses use the technology as management has intended. In other words, the technology must contribute to decreasing the vari-

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ability of nursing care. Only if nurses' work is routinized in this manner will administrators succeed in exerting more control over the labour process. Thus it is in the best interests of administrators to facilitate staff acceptance of these technologies. The Computerized Information System There are few studies available which examine the implementation of computerized information systems within a hospital setting. The ways in which nurses incorporated the technology into their work has been largely ignored. A discussion paper published by the Australian Nursing Federation15 does address some of the effects of a computerized information base, but the report adopts a strong technological determinist stance, implicitly accepting the inevitability and desirability of computerization. Not discussed is management's rationale for introducing the technology. The report does not address the potential conflict between the goals of management and those of staff nurses, nor does it consider the adjustment of nurses to the new technology. It adopts a very positive and optimistic tone when dealing with the impact of technology on nurses' work, conveying the message that computers will naturally benefit nurses. Similar difficulties are apparent in a Canadian study sponsored by the National Federation of Nurses' Unions16. Once again, the impact of computers in nursing is examined incompletely. The study neglects the issue of increased management control over nursing care and, operating from a functionalist perspective, treats the arrival of the computer as the starting point of discussion and views the computer as a natural/evolutionary product. It ignores management rationale, treats the implementation process as unproblematic, and does not consider how nurses adjust to the system change. Thus, both the Canadian and Australian studies not only neglect management's role in introducing computer technology, but also portray nurses as passive and unable to alter the effect of these systems on their labour process. The observations and interviews conducted for this case study indicate a more complex, even contradictory, process. It is important to note that, during the study, a hospital-wide computer system was just being introduced in stages. At that time, all nursing units were equipped with at least one computer terminal, but the system was not yet fully incorporated into the setting. The computer was used to convey information regarding patient census and location, dietary changes, laboratory reports, and other general communication between departments. Management intends that eventually the computer will function in all areas of patient care and support.

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Many departments within the hospital had experienced staff reorganizations during the incorporation of the computer systems. One of the observed changes was that fewer staff were available to carry out tasks in the old, precomputer way. For example, prior to the computer, many departments exchanged information over the telephone. This exchange of information was now supposed to take place using the computer. To encourage this, budgets were reorganized and tasks altered so that individuals had little time to convey information via the telephone. Management, in an effort to rationalize the workplace, had created a new work organization to enhance the new technology. More specifically, management had found a technology which they believed would help them to rationalize the workplace. The new technology supports the new organization, and the resulting changes in the nature of work exert pressure on the worker, in an attempt to prevent her from functioning as before. The lab technician now has little time to answer the phone because of the reorganization of her work. The nurse who calls the lab for reports, rather than using the computer, is likely to be greeted by an angry technician, and is encouraged by this reception to use the computer in future. In this way, management hopes to effect change by forcing the workers to exert pressure on each other. Although the study took place very early in the implementation of this technology, there were indications that all was not changing as the administration had apparently hoped. There was resistance to the technology. The most frequent users of the computer were the ward clerk and the charge nurse. There were many complaints by staff nurses about the particular system in use. A few of the nurses accepted in principle the idea of a computerized system, some with marked fatalism. That's the future of nursing, isn't it? Most of the paper work will be done this way

However, many staff nurses avoided the computer and continued to use the telephone to communicate diet changes or obtain lab results. Many nurses interviewed complained that the computer would increase, not decrease, their workload and gave examples such as the following to support this prediction: Nurses transferring patients to another ward would first phone the floor receiving the patient to find out the exact room and bed number to which the patient was moving. This information would then be entered into the computer and sent to all departments. In other words, the nurses found it necessary to combine some of the 'old7 ways with the newer, computer-mediated tasks in order to get the work done.

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According to those interviewed, management had assured nurses that tasks would eventually be streamlined. But many expressed disbelief. The following comment was typical: Even to send messages to the dietary department...it's just a lot easier to pick up the phone. I tend to avoid the computer if possible.

In spite of management intent, and the technology itself, many nurses were refusing to change their work practices. Nurses were exercising some resistance by refusing to use the computer some of the time. On the other hand, the administration was committed to ensuring compliance by reorganizing work structures. Because the technology is still in the very early stages of incorporation, any conclusions at this time would be premature. The Patient Classification System The patient classification system has been in use longer than the computer; it was introduced in the unit about two years prior to the case study. The same classification tool, with minor variations, is in use throughout the hospital. As with computers, there is very little information available about the implementation of patient classification systems into nurses' work. One notable exception is the research by Marie Campbell, who attributes the adoption of patient classification systems to management's need to increase control over nursing care. She describes this technology as a tool that objectifies and rationalizes patient care. To accomplish this, the system transforms knowledge, once controlled by nurses, into standardized expectations. Nurses, she argues, become oppressed by this objectified knowledge, because these standard expectations constrain nurses from freely caring for patients.17 For example, the system assumes a standard treatment time for all patients requiring a bed bath. Additional or different care requirements are not considered. Although Campbell provides an extremely thorough analysis of the patient classification system, she describes the relationship between the system and nurses as very deterministic. In other words, the system is presented as automatically causing compliance by nurses, and nurses, in turn, are portrayed as passive victims of this situation. Nurses enter their knowledge into information systems, and in so doing, participate in the documentary management...exercised over their activities.

Missing in this analysis is the possibility that nurses could act against the system.

681 Vital Signs The system operates...to displace [nurses'] capacity to exercise their professional judgement18

Although nursing knowledge has formed the very basis of the patient classification system, Campbell does not consider nurses themselves to be capable of resistance, even when the system works against the delivery of good nursing care. This case study examines the implementation of a patient classification system in the hospital unit studied. The analysis looked at the reactions of nurses to the introduction of this technology, including how successful management has been in justifying the need for the system. Were nurses using the system in the recommended manner? Had management succeeded, as Campbell indicates, in oppressing nurses and exercising control over nurses' knowledge? Do the nurses believe that patient care has changed since the introduction of patient classification? What effect has the system had on job satisfaction? (A later section of this paper discusses the ways in which these nurses believe their skills have been influenced by the technology.) Nurses working in one critical-care unit of the hospital studied were observed and interviewed over several weeks in late 1988 and early 1989. In using the classification system, nurses were required to circle numbers which corresponded to appropriate nursing care levels for each patient. The predetermined types of care, care levels (or intensity), and corresponding " values" were listed on sheets of paper that were added to each patient's chart on admission. A total value, representing the amount of care required by each patient, was calculated three times daily: 4:00 a.m. 10:00 a.m. and 4:00 p.m. Nurses in the critical-care unit indicated that they calculated these numbers more frequently than did nurses on most other units. The nurses explained that this was because in a critical care area patients are less stable, and therefore staffing needs fluctuate more frequently. Still, the intent of even the frequent calculations was to eventually arrive at a reliable average, thus allowing staff levels to be predicted at least one shift in advance. During these set times, the nurse is supposed to review the care choices and, according to the patient's condition at that time, circle the number which represents the appropriate level of care. Each patient's total care number is given to the charge nurse, who calculates a total patientcare value for the entire unit. For example, under the subheading " Nutrition," a patient who feeds herself is " 1", one requiring some assistance is " 6", and one needing total feeding assistance is " 15." The higher numbers signify the need for more nursing care. The overall ward total is then used to assess the number of

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staff required for the day. The staff nurses were not involved in establishing the worth attributed to each category of care; the values were predetermined. As it had done with the computer system, management used staff to monitor one another's compliance to the patient classification system. Staff nurses were expected to carry out audits of patient-care assessments on other wards. Each unit was responsible for conducting audits on one other floor; a compliance " buddy system/' The staff in the critical-care unit under study was required to perform three audits weekly, and one of the staff nurses was delegated this duty by the head nurse or charge nurse. During an audit, the patient-care hours which have been calculated by the nurse caring for the patient are checked against the nursing-care plan and the patient " Kardex." The nurse caring for the patient is therefore " checked" in two ways: Her patient-care plan and the Kardex are examined to ensure the presence of up-to-date treatment information, and the patient classification numbers are checked for completeness and accuracy. By incorporating this policing action into the regular work routine, management has moved to ensure the implementation of the system. Nurses are monitored by one another, and those not using the patient classification system, or using it" incorrectly," will be discovered. This is yet another example of management altering the structure of work in order to incorporate a new technology. Resentment of the patient classification system was widespread among nursing staff. Those who were interviewed complained that the calculations were time-consuming and a waste of time. One nurse said, Ifs not as bad as it was initially, but it's my last priority during the day. The nurses were rarely seen calculating the patient-care hours at the designated times. Some nurses completed their 10:00 a.m. classification immediately following report at 8:00 a.m., often before they had seen the patients. Similarly, the 4:00 a.m. classification was often completed before midnight. At other times, a busy nurse would be unable to consider the patientcare hours until well past the appropriate time. Some charge nurses would remind these individuals, but others would complete the numbers themselves, sometimes without seeing the patient. Tension would occasionally result if the staff nurse resented the reminder or the interference in her patient care. The observation that nurses calculate the patient-care hours at non-specific times, often without examining the patient, indicates, at the very least, a resistance to using the instrument as management intends. Other indications of this resistance are evident in nurses reinterpreting or changing

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the care levels of their patients or exaggerating the amount of care required, so that the patient is documented as requiring more attention and the unit is registered as needing more staff. The following comment illustrates one nurse's resistance to the system. There is a lot of confusion about what the categories mean. In the section for nutrition, some staff rate what we routinely do here as " self-feed'' [a value of 1]. But we take the tray off the cart, carry it into the patient's room, and set the patient up to eat. Now, on the other floors— the regular floors—the dietary staff do all this. So there's no way to account for the difference in time, yet we are told to consider this to be " self-feed" ....I don't. I mark it as " feed with assistance" [ a value of 6].

Some observations, however, indicate that the nurse's autonomy is endangered. Staff nurses themselves are policing the implementation of this technology, and therefore acting on behalf of the administration, against each other. There are contradictory observations regarding the audit function. Many nurses seemed uneasy when the auditing nurse arrived. During these visits, charts would be reviewed at random. The nurses did not seem anxious to have their own charts examined, and sometimes spirited exchanges occurred if the audit nurse disagreed with the nurse caring for the patient. But when asked outright if they resented the process, nurses said no: I don't feel threatened by it. I'm not resentful. If anyone asks me why I have a certain score, then I can substantiate it. That's what is so crazy about this system—there are so many interpretations for each category.

There were also contradictory reactions by staff nurses to the role of the administration in implementing the system. Each nurse interviewed stated that her initial belief had been that the patient classification system was established to help justify more staff. Administration presents it to us that we will be able to get more staff... to prove to the government that we should be better staffed. I realize that it is effective because it justifies staffing needs, but it really is a bother. They [administration] told us that it would increase our staff numbers...that it was for the nurses' benefit. They told us that they needed proof of how busy we were to get more staff.

The nurses frequently expressed displeasure that the administration was not fulfilling its promises.

Nurses and Patient Information Technology / 71 Administration never uses it to increase staff. In other hospitals I've worked, where they use the system, I have had trouble getting extra staff. Nursing Office has said to me," your [numbers] don't reflect that need/'

Some nurses assessed the administration even more cynically: Just another example of administration dumping on nurses again. The attitude of nursing administration is that we can manage...we can always manage. At one point, I had to call the nursing supervisor and tell her that I would not be responsible for what happened on the floor,.. .we were so short-staffed. She said...she'd see what she could do. We didn't get any nurses.

It is interesting that nurses who express such general distrust in the administration shared an initial optimism about this patient classification instrument. The degree of success enjoyed by the instrument thus far is, in part, a result of its divisive nature. Individual nurses are placed in conflicting roles, as are different nursing units within the hospital. In addition, the administration has made the system's monitoring function seem part of the technology itself. Hence the monitoring is viewed as integral to the system, not as a way of ensuring compliance. Although the intent of the administration in using this type of monitoring system may be to appear only indirectly involved, the nurses seem very aware of management's role. The nurses were vocal in their disappointment that staff levels had not increased as a result of the patient classification system. It was surprising that none of the nurses interviewed mentioned that the technology could have been intentionally introduced as a means of reducing, rather than expanding, staff. In observing the nurses, it was apparent that the rationalizing goal of decreasing the control of the individual staff nurse had not, as yet, been achieved. The nurses interviewed continued to differentiate between their own knowledge and experience and that represented by the technology. This was apparent in the amount of disagreement about the " value" assigned to certain activities. Throughout the study, the nurses regarded the instrument as separate from their nursing knowledge. They considered the classification instrument merely more bothersome documentation. In other words, it was viewed as just another type of charting, another place where the nurse's knowledge and experiences were recorded. The nurses studied did not consider that the instrument was able to qualitatively inform their nursing care.

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Skill

Discussions of the effect of technological change on workers' skills/like those concerning the implementation of new technology, have often suffered from simplistic approaches. Specifically, a frequent debate occurs between those who characterize skill as an objective, quantifiable phenomenon and those who define skill as completely socially constructed. Those who make the latter claim often describe skill as a political construction: a label that is won as a result of struggle, not because of any innate character or quality of the work itself. Among those who believe that skill is an objective entity are traditional, often functionalist, theorists who insist not only that skill is an obvious characteristic, but also that the labour force has become increasingly skilled. The presence of sophisticated technology is often referred to as proof of the workers' greater levels of skill. Although this technological determinist view was most prevalent during the first half of this century, it continues to attract support.19 Braverman also presents skill as an objective and quantifiable phenomenon, but one that has diminished, not increased, with capitalism. Deskilling occurs, he maintains, because of the capitalist's need to counter competition through increased production. To accomplish this, it is important for the capitalist to gain complete control over the way in which work is done. To achieve this end, technologies are introduced which rationalize the labour process. Rationalization means that the worker is separated from his or her skill; the conception of work is dissociated from its execution. Control over the knowledge of production, or how best to perform certain tasks, shifts from the worker to the manager. So, in contrast to the functionalist argument which assumes that sophisticated technology needs skilled workers, Braverman asserts that such technology may instead require workers with only minor skills. To the benefit of the profit-conscious owner, the work is increasingly simplified and routinized, and the deskilled worker is easily replaced.20 Gaskell disagrees with Braverman's deskilling hypothesis. She argues that skills are not obvious, easily recognizable phenomena. Instead, she defines skill as a social construction, the result of political struggle. The skill label, she maintains, has often been used as a political weapon in the workplace. In some cases, management has awarded skill status to certain groups of workers in an effort to reduce labour cohesion. In other cases, labour organizations have also been successful in acquiring the skill label, and accompanying benefits, as a result of worker resistance. The skill label, she argues, is awarded or withdrawn without regard for the actual characteristics of the job.21

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Neither of these approaches analyses skill adequately.The traditional functionalist approach neglects the history of labour-process change and the ways in which the capitalist seeks to increase control over the work and the workers. In other words, the technology is viewed as somehow unrelated to the goals of those who introduced it. As well, neither Braverman nor Gaskell, in isolation, is able to satisfactorily examine the effect of technological change on the labour process. The deskilling argument ignores the unevenness of organizational and technological change in the workplace. Some workers have increased their skills, and some new skills have emerged. In addition, Braverman tends to idealize the precapitalist craft worker, and presents an over simplified, highly romanticized description of work during that period. In contrast to Braverman's view, the craft worker can be subordinated to capital interests, and non-craft labour can prove most resistant to capitalist demands.22 Another difficulty with Braverman's premise is its neglect of sex as a skill-defining variable. In other words, the work performed by women tends to be undervalued and labelled as unskilled precisely because women are doing the work. This devaluation is due in part to women's low involvement in labour organizations. But even when women are union members, their needs have often been sacrificed for those of the men. Due to the particular historical combination of capitalism and patriarchy, the worth of women's work has not been officially recognized.23 Nurses, as will be discussed, have had their work undervalued in this way. Although there are problems with the conception of skill as an objectively measured category, there are also difficulties with the argument that skill is entirely socially constructed. Gaskell demonstrates this difficulty in her treatment of skill and skill assessment. She describes a comparison of men and women according to their levels of skill, and on the same page, declares that this comparison is impossible.24 Gaskell's inconsistency indicates that in certain situations, skill does have an objective component. A concept of skill as socially constructed does not exclude a concept of skill as having an objective component. A synthesis of these views is necessary to understand skill fully. For example, a particular worker may experience an objective change in her work, but how this change is understood depends on the social relations of the workplace, including changes in technology. An adequate analysis of technological change must consider not only the technological artifact itself, but also why the tehcnology was introduced and how the worker responds. Skill is an integral part of this complex an sis. Skill, as both social construction and objective phenomenon, may affect how new technologies are received by various workers, and the new tech-

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nology may, in turn, affect the skills of those who use it. The analysis must also consider class relations, the sex of the worker, and the role of the state. Any analysis of technological change must also deal with the problem of how to recognize the presence of skill in work. Braverman's analysis is straightforward in its definition of unskilled labour, but he is less clear when defining skilled work, other than his highly idealized description of the " craftsman" [sic]. We are informed that skilled work is the opposite of mechanical, routine, and repetitive work. Generally, Braverman considers work to be the unhampered association between the worker's conception and execution of his or her labour. In other words, the worker freely conceives of what needs to be done and then is free to do it.25 Meissner discusses the inadequacy of simplistic skill definitions. An improved understanding of skill, he argues, can be approached only by constructing complex, descriptive categories. In addition to Braverman's analysis of the importance to skill of control over the work process, Meissner lists other identifying features: the presence of a tacit knowledge base and the necessity of integrating many tasks at the same time. Only by including these features, Meissner argues, will the hidden skills of much of women's work be identified.26 Yet identifying women's working skills is even more difficult than Meissner's analysis indicates, because many tasks have traditionally been labelled as instinctive or natural to women. This is especially true of the caring work performed by nurses. Much of the knowledge base used in helping patients through their daily activities is hidden. In other words, those skills involved in bathing, clothing, feeding, observing, listening to, and sympathizing with patients are not recognized as learned or skilled.27 Nurses and Skill For this study, the concept of skill includes an assessment of qualitative changes in the nurses' labour process, resulting from the introduction of the two information technologies: the computer information system and the patient classification system. In order to capture the true essence of skill change, the study focuses on indications of rationalized or mechanical work. For example, in using these systems, does the nurse exercise less discretion in her work? Are there indications that all patients with the same illness are treated exactly the same, regardless of individual need? Does evidence exist that the technology has become more credible, or is trusted more often, than the nurse's own knowledge or experience? The study also examines whether nurses perceive that these technologies have decreased their ability to respond to patients individually. What degree of control are nurses able to exercise over their work? In other words, are there indications of a considerable tacit knowledge base? Are nurses

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rejecting or altering work practices arbitrarily, or have the technologies had influence here? Less obvious, but also important, is evidence of experience taking precedence over standing orders or hospital policy. This is an indication that the nurse is able to assess the worth of certain practices and alter them if necessary—an indication of skill. Also important in any skill assessment is the ability of the worker to integrate several concurrent tasks. Has the technology interfered in any way with a nurse performing such tasks? Further, do the systems take this characteristic of skilled work into account? In addition, any examination of work which is performed primarily by women must incorporate the reality of women's subordination. Women's work is more likely to suffer deskilling precisely because of this subordinate position. Relevant, then, is whether the new systems have facilitated this subordination. This examination of nurses' work also takes into account the subtle character of women's subordination, which may cause nurses' skills and work to be undervalued to a greater extent because most nurses are women. Thus it is important to be particularly sensitive to the hidden skills in nurses' work; to look beyond the traditional, male-specific, and, in this case, medically dominated conception of skill. The literature provides divergent opinions on whether nurses have become more or less skilled. Many authors claim that nurses' skills have increased as a result of technology. Given the increasingly technical nature of skill, they argue, the reality of total physician control has become impossible (if indeed it ever existed). With the advent of highly specialized nursing units in most hospitals, nurses have become experts who can and do make critical, life-saving decisions, since waiting for a doctor could well be lethal for the patient.28 To argue that nurses are increasingly skilled because they work with sophisticated equipment is yet another application of the old functionalist argument discussed earlier. The logic is faulty, particularly considering that in order to gain competitive advantage, manufacturers of medical equipment have made it increasingly easier to use. For example, taking an electrocardiogram is much faster now than in the past. Also, electrocardiograph machines are now equipped with computerized diagnostic capability. A printout lists abnormalities in heart rate and rhythm, in effect diagnosing the condition. Although nurses in this study stressed that they did not completely rely on the machine's diagnosis, some did admit that, in an emergency situation and with fewer staff, it would save time if the machine could be completely trusted. In that case, the knowledge base required by those using the equipment would not have to be as extensive.

76 / Vital Signs The more sophisticated machinery may actually require a much less sophisticated user. The stance that sophisticated equipment requires sophisticated users ignores the administration's reasons for introducing the technology. A devaluation and deskilling of nurses' work, in the presence of increasingly sophisticated technology, would enable administrators to hire those who do not possess such a complex knowledge base and who could therefore be hired for lower pay and controlled.more easily An analysis of skill and technology must consider how the technology is used, whether the nurse is merely a monitor, and how much of her own knowledge is in use. Some have observed that nurses are drawing closer to the skills of doctors by using this technology. It is possible, though, that the technology is working to deskill doctors as well. Theories of nurses' skill that rely solely on the technology itself, or that display technological determinism, also perpetuate a gender bias. For example, nurses who work in highly technical settings, such as the intensive-care unit, are often considered to be more skilled than their counterparts on, for example, general medical wards. The workers who are rewarded and recognized as skilled are those whose tasks most closely resemble the work of physicians: those who use sophisticated machinery, or whose work is carried out in the presence of such equipment. The caring skills remain unacknowledged and are rated lower than the high-tech activities. As Diamond argues, caring is invisible in the language of business and medicine, and .. .written out of the charts.29

Official hospital records differentiate between actual" treatments" and caring duties, with treatments considered to be much more important in the pursuit of good health. Arguments which contend that nurses will become increasingly skilled as a result of new technology often point to the increased level of education required. The Royal Australian Nursing Federation commented: [With the advent of computers], nurses with more sophisticated skill and knowledge will... be needed. These nurses will require more advanced education.30

The claim that increased educational attainment translates directly into greater skill is also contentious. Gaskell argues that there is not necessarily an exclusive relationship between formal education and skill levels. Instead, she maintains that skills can develop from different sources.31 Thus, skills may also develop in the workplace, or be acquired in less formal settings. But relevant to this discussion is the contention by many

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that skills acquired in a less formal way are likely to be rated as less important. This has a direct influence on how nurses' work is valued, since a great deal of nursing knowledge and experience is attained after formal education or training is completed.32 Thus, in the social construction of skill, formal educational attainment is awarded greater value and prestige than less formal learning. Many who argue that nurses have become deskilled point to the hospital hierarchy as causal. Stromberg comments: [Nurses are] limited by the formalized, hierarchically structured work environment that encourages routinization of tasks rather than individual experimentation.33

Unfortunately, Stromberg's argument that nurses' deskilling is a product of the hierarchy is simplistic in its neglect of those responsible for maintaining the hierarchy and who have an interest in its perpetuation. Instead, Stromberg portrays nurses as helpless and powerless against a faceless structure, and her analysis ignores the dynamic nature of work organizations. Bellaby and Oribabor, who also contend that nurses have become deskilled, argue in a similar vein that most nursing care relies on routine or standing orders. The nurse, in their analysis, is but a monitor of equipment, one who hastens to call a doctor if any unexpected events occur. This deskilling, they maintain, is a product of medical dominance, medical technology, and the influence of capitalist organizations which supply drugs and equipment.34 Although these authors present a more complex discussion of skill, the nurse is still characterized as passive and helpless in her acceptance of the change in her work. Furthermore, Bellaby and Oribabor ignore the problem of dispensing standard care to a highly diverse patient population. Numerous bedside contradictions and conflicts result when routine or standardized care is attempted with a non-standard patient. Skill and the Computerized Information System There are few studies available which specifically examine the effect of computerized patient information systems on nurses' skill. The articles making up a report by the Royal Australian Nursing Federation are more concerned with outlining new ways in which the technology could be used. How the system could affect nurses and their skills is not addressed. [A] computerized nursing information base... [will be the product of] the increasing data base afforded by nurses entering ... into the computer ...assessments!,]. interventions.. .[and] evaluation[s].... From this rich and

781 Vital Signs scientific... base will be derived standardized nomenclature [of nursing practice].35

A frequent argument waged in support of computerized technology is that the data, not the nurses, are automated. The nurse, it is argued, remains able to respond freely, using her extensive knowledge base.36 This declaration seems overly optimistic: It ignores the possibility that the computer technology reflects an attempt by the administration to exert greater control over the work of nurses. The computer is now being used to standardize nursing care; nursing knowledge is increasingly organized, stored, and disseminated using this technology. But there is an additional type of control that is mediated by the computer: the calculation of patient-nurse ratios. Although the case study hospital was not yet experiencing computerized staffing, it soon would be. Once fully implemented it will severely curtail the nurses' freedom to make treatment decisions.37 A Canadian study by Desborough, sponsored by the National Federation of Nurses' Unions, sought to examine the impact of computers on nurses. The finished report, however, concentrates mostly on issues external to questions of skill or patient care. The true effect of this technology on nurses' work quality is ignored. A few sample questions are listed below. -Are you kept informed of changes to the system? -Are adequate policies/procedures in place regarding computer security? -Is location of the printer a problem?38

Many of the questions concern the ergonomics of incorporating the machinery. Only fifteen of the forty-nine questions concern actual work quality To these work-quality questions, most nurses responded that the computer made little positive difference. For example, more than 81 per cent of those surveyed denied that the computer decreased their workload, approximately 77 per cent of nurses that patient assessments did not improve with the advent of the computer, and 75.5 per cent stated that the computer had not improved communication with either patients or staff. Of the remaining questions that pertain to work or skill, only one response demonstrates a more positive opinion of the computer technology. When asked if patient care was based on more current information, using the computer, 44.5 per cent answered Yes and 47.6 per cent answered No. Desborough posits that nurses were referring to the faster delivery of lab results through the computer.39 Also related to the issue of skill and control is the response by 64.4 per cent of the nurses that they were unable to alter the computer system in order to improve their work.40 This could indicate that many nurses find

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the computer to be inconsequential in performing patient care. But it could also mean that nurses view the computer with a certain amount of awe, regarding it as a powerful knowledge disseminator rather than just a method whereby nurses' own knowledge is organized. Unfortunately, many such critical issues were ignored in Desborough's study. The dearth of qualitative research on the effect of these systems is due in part to the relative youth of the technology. Hospitals are only now in the process of implementing these technologies; few have completely computerized. As such, many of the workers in contact with the equipment are only beginning to assess its impact. But the lack of analysis also reflects a refusal by many who work within health care to address the similarities between hospitals and other work settings. The experience of other workers facing technological change has not been incorporated, on a large scale, in understanding the changes occurring in hospitals. The nurses interviewed for this case study did not consider any of the work required on the computer to be skilled. The computer work was relegated to the category of " paper work/' Those interviewed also differentiated between " paper work" and " nursing care"; the former was often viewed as interfering with the latter. Compared with other [places] I've worked there's just so much paper work here. I only seem to have time for essential contact with my patients. It's so bad some days that I actually feel annoyed if my patient has chest pain...especially if I am behind in my paper work....I feel so guilty. I mentioned this feeling to some of the others. They said they felt the same way. It is just too much paper work.

The belief that nurses will also suffer as other groups begin using the computer is widespread. In particular, there were numerous comments regarding the next planned stage in incorporating the computer: its use by doctors to write patient orders. The next step...is to have all doctors' orders on the computer. But who do you think will actually do this job...ward clerk or nurse? Doctors ordering on the computer. That's a joke...we can't get them to write simple orders now. Do you think we'll get them on the computer? No way. It will be the nurses.

It was expected by many of the staff that nurses would be forced to complete the doctors' unfinished work. Given this further increase in paper work, nurses would have even less time for patient care. Considering how unimportant and unskilled nurses consider paper work to be, this would result in even less time spent practising skilled nursing work. Again, there was a sense of inevitability about this expectation. None of the nurses spoke

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in terms of working to change this situation. Evident in the interviews was nurses' sense that they were more likely than other health-care workers to experience adversity during these times of change. In sharp contrast to the nurses' perceptions of little control were their attitudes towards patient care. The nurses repeatedly declared patient care to be their priority, and maintained that the computer had little positive impact on this activity. Generally, the computer seems just to add more work. There are more sheets for lab reports It takes more time. You are constantly updating the reports and replacing outdated ones. It [computer] does nothing for patient care. It just pulls us away from the bedside. We aren't taking the same time and care in performing our skills. We can't. Technology has decreased our skills in communication, particularly with the patient. The computer doesn't increase our skills... typing skills maybe, but that's about all.

The nurses indicated that the administration has had little positive impact on patient care. Instead, some stated, administrators could be counted on to interfere. Mixed with their expressions of low control, the nurses also expressed a sense of superiority which seemed to be based on the belief that patient care is the critical nursing function. The administrative, paper-work requirements did not, according to those interviewed, substantially improve patient care. Therefore these administrative changes were considered relatively unimportant. At this stage of implementation, the computer seems not to have interfered directly with nurses' skills. There is no obvious rationalization or routinization of work. There are, however, indications that the technology has already resulted in less patient-care time. Although it would be premature to predict how this technology will affect nurses' work once fully implemented, there are, according to those interviewed, very disturbing trends. Skill and the Patient Classification System As previously discussed, Campbell has usefully analysed the relationship between patient classification systems and skill. This type of technology, she argues, devalues the knowledge base of the nurse. When control over knowledge or skill shifts away from the nurse to a document-based form, the nurse is more severely constrained. Management, working within the financial constraints of a capitalist organization, strives to increase control over nurses by objectifying nursing knowledge. The patient classification instrument is central in achieving such objectification. And the

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desired result of the increased administrative control is a reduction in the cost of care. Campbell maintains that the patient classification system promotes a deskilling of nurses; that nurses were, prior to the incorporation of this technology, in control of their knowledge and its practice.41 The patient classification technology was in a very early stage of implementation in the hospital under study, and there are some observations that contrast with Campbell's findings. An intact and tacit knowledge base was evident in the finding that nurses reinterpreted the technology. As discussed, the nurses were observed and quoted as disagreeing with the values accorded certain care activities. The work had not yet become mechanical (yet another indication of deskilling) because the nurses continued to interpret the care levels differently. Some of those interviewed did portray the technology in a positive light. One nurse commented that the frequent documentation of the patient's condition required by the system helped her to remember important events and thus made her charting more accurate. It helps me monitor myself. Sometimes I do things and forget to document it...so it's helpful. It also forces me to update my nursing care plans.

But she adds It does nothing for patient care, unless you are floated out to another floor, then it might be useful in helping you care for a patient in an area that is unfamiliar.

Some of the nurses believed that patient care could be reduced to a numerical value, an objectified standard. For these nurses, the only problem was finding the most accurate system to accomplish this. One nursing administrator commented: F ve seen it work. There are many days when I look at the staff we have and then do a quick calculation. The numbers [using the patient classification system to assess patient-care load] have been right on.

Other nurses also accepted the legitimacy of the system, but expressed concern over its suitability within a critical-care environment, due to the presence in this setting of less stable patients. Two such comments follow. It's different in, let's say...a medical floor where there is more chronic care. There I see it would be helpful in planning staff. I just don't see how you can be judged for overstaffing on a budget for this type of unit. If a patient warrants more care, he should get it.

These comments seem to implicitly accept that nursing care can be measured by an external instrument. Even some of those who appear to chal-

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lenge the logic end by arguing only that this particular instrument is illsuited to that particular setting. One staff nurse commented I doubt that you can ever grasp the whole patient with it. You can work like crazy on a patient who comes in really sick, and is transferred to another unit or to the OR.... But if all this happens between classification times, the whole thing is missed. How can you staff according to that?

Even though the initial sentence appears to question the overall validity of the instrument, the nurse spends more time arguing for a new, improved version of the technology; one in which the entire day, not merely specified times, could be included. Many nurses were more critical of the patient classification instrument: I don't think this should be our responsibility. Why should I have to be proving what I do? Medical care isn't numbers, its people. I really resent having to prove that I'm doing my job. If they want to see if I am, then they should come up and do the numbers themselves. Administration is yet again taking the easy way out....Sometimes you just have to dig your feet in and say/' I'm a professional, so I am responsible for this patient's care."

These comments also contain contradictory messages. There is some obvious support for occupational autonomy and a resentment for having to prove one's capability. Yet these occur simultaneously with some implied acceptance of the technology. The nurse who suggests that administrators should come to the floor and do the care calculations th selves is not directly refuting the validity of the instrument. Even some of the nurses who openly dislike the classification tool consider its presence to be more of a nuisance than a threat. The [patient classification] system has been no help in improving my nursing skills at all. I don't think a lot of this technology affects my nursing skills at all. It does,however, take up a lot of my time.

Not one of the nurses interviewed suggested that the patient classification system could deskill her work. The tool was regarded as an inconvenience, and by some as yet another example of administrative bungling. The idea prevails that real nursing care remains isolated from this " paper work/7 The responses of nurses to the computer and patient classification technologies have been contradictory. On the one hand, administrators have

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successfully introduced these systems along with various monitoring techniques. Workers are positioned to coerce one another into compliance. T lab technician, having no time to answer telephone queries, demands that the nurse use the computer. The nurse who audits how other nurses use the patient classification system reports to administration on how " well" each ward is complying with the technology. On the other hand, there is resistance. Nurses are not using these technologies as intended. The computer is often avoided. As well, the patientcare calculations for the classification system often represent inflated time estimates and are completed at inappropriate times and with incomplete reference to the patient. It is too early in the implementation stage to assess the impact of these technologies on nurses' skills. There were no obvious indications of deskilling in this study. Evidence of tacit knowledge existed; nurses were observed to be relying on experience and integrating concurrent and varied tasks in their work. But there are also contradictory findings here. Administrators, by instituting these systems, are moving towards increasing control over the work performed by nurses. To accomplish this, the opinions and assessments of nurses are de-emphasized in favour of objective information provided by the technologies. Thus, situations occurred in which a nurse's assessment of staffing needs was refuted because the ward " numbers" did not indicate the need. In other words, because the patient classification system did not signal the need for extra staff, there was no need, regardless of the nurse's statements. The nurse's skill and experience were therefore devalued. Most of the nurses interviewed did not express a belief that the technology was depriving them of their skills. But if this technology is to become the primary determinant of staffing numbers, and if nurses' opinions and experiences are ignored over time, then skill may well suffer. Staff nurses were not consulted when the patient classification categories were established. When this system combines with the computerized staffing program, the ability of nurses to respond to individual patient needs may well be curtailed. Staffing ratios will automatically determine the amount of care permitted for each " type" of patient, and it seems quite possible that a knowledge base could be undermined in this setting. Again, it is premature to state that automatic deskilling and loss of control over work will necessarily occur without resistance. To deny the possibility of resistance would both ignore the contradictions of change and present nurses as very passive workers. Indeed, there are indications among those interviewed that trust in the administration is very low. In addition, there are signs of resistance to the systems. In order to more fully understand nurses' reactions to these technological changes, a more

841 Vital Signs

extensive study, one which includes a variety of settings at various stages of technological change, is imperative. The belief voiced by many nurses that patient care will somehow remain isolated from administrative changes to the organization of work is based on simplistic conceptions of technological change and skill. Nurses would benefit from examining the impact of technological change in other settings, particularly other female-dominated occupations. In addition, consideration of skill as a social construction would aid in this analysis. Important as well is a critical analysis of the medical model. This model, which supports a conception of health care as an objective science and reduces people to mere body parts to be fixed, contributes to an acceptance of a rationalized nursing care. This, in turn, implicitly welcomes a patient classification system that serves to rationalize care. The nurse and patient both suffer if a one-dimensional system, such as the patient classification system, is allowed to inform and eventually restrict the complex and multidimensional knowledge, experience, and activities that make up nursing care.

Notes 1. Chris DeBresson and Margaret Lowe Benston, " Introduction/' in Work and New Technologies: Other Perspectives, ed. Chris DeBresson, Margaret L. Benston, and Jesse Vorst (Toronto: Between the Lines, 1987). 2. J. Hamner and D. Leonard," Negotiating the Problem: The DHSS and Research on Violence in Marriage/' in Social Researching: Politics, Problems, Practice, ed. C. Bell and H. Roberts (London: Routledge & Kegan Paul, 1984); and Ann Oakley, " Interviewing Women: A Contradiction in Terms/' in Doing feminist Research, ed. Helen Roberts (London: Routledge & Kegan Paul, 1981). 3. P. Attewell, " The Deskilling Controversy/' Work and Occupations 14 no.3 (August 1987). 4. Harry Braverman, Labor and Monopoly Capital: The Degradation of Work in the Twentieth Century (New York: Monthly Review Press, 1974). 5. Ibid.

Nurses and Patient Information Technology / 85 6. T. Elger," Braverman, Capital Accumulation and Deskilling," in The Degradation of Work? Skill, Deskilling and the Labour Process, ed. Stephen Wood (London: Hutchinson, 1982). See also Stephen.Wood, "Introduction," ibid. 7. Armine Yalnizyan," The Impact of Technological Change on Hospital Workers" (Toronto: Service Employees International Union, Local 204, May 1986). 8. D. Coburn, G. Torrance and J.M. Kaufert," Medical Dominance in Canada in Historical Perspective: The Rise and Fall of Medicine?" International Journal of Health Services 13 no.3 (1983). 9. Quoted in Nicholas Regush, Condition Critical (Toronto: Macmillan, 1987), 78-79. 10. Lesley Doyal, The Political Economy of Health (London: Pluto, 1979). 11. Marie Campbell," Information Systems and Management of Hospital Nursing: A Study in the Social Organization of Knowledge" (Ph.D. thesis, University of Toronto, 1984) 12. Yalnizyan," The Impact of Technological Change on Hospital Workers." 13. A.G. Paget," Planning for Grasp," as quoted in Yalnizyan," The Impact of Technological Change on Hospital Workers." 14. Ibid. 15. Royal Australian Nursing Federation, " Introduction," in Computerized Patient Data and Nursing Information Systems: Some Considerations (South Melbourne: RANF, 1984). 16. K. Desborough, " Infostat: A National Study on the Impact of Computers on Nurses" (Ottawa: National Federation of Nurses' Unions, 1987). 17. Marie Campbell, " Productivity in Canadian Nursing: Administering Cuts," in Health and Canadian Society: Sociological Perspectives, 2nd edition, ed. D. Coburn, C. D'Arcy, G. Torrance, and P. New (Markham, Ont.: Fitzhenry & Whiteside, 1987): Campbell, " Information Systems and Management of Hospital Nursing. 18. Campbell, " Information Systems and Management of Hospital Nursing," 3-4. 19. Stephen Wood," Introduction," in Wood, The Degradation of Work.

861 Vital Signs 20. Braverman, Labor and Monopoly Capital. 21. Jane Gaskell, " Conceptions of Skill and the Work of Women: Some Historical and Political Issues/' in The Politics of Diversity: Feminism, Marxism and Nationalism, ed. R. Hamilton and S. Barrett (Montreal: Book Centre, 1987). 22. Veronica Beechey," The Sexual Division of Labour and the Labour Process: A Critical Assessment of Braverman/' in Woods, The Degradation of Work?. See also Elger," Braverman, Capital Accumulation and Deskilling." 23. See Gaskell, " Conceptions of Skill/' and Beechey, " The Sexual Division of Labour," for discussion of the undervaluation of women's work. 24. Gaskell, " Conceptions of Skill," 362. 25. Braverman, Labour and Monopoly Capital. 26. M. Meissner, " Working Knowledge in the Office and the Household," paper presented at CSAA Annual Meetings (Windsor, 1988). 27. Timothy Diamond, " Social Policy and Everyday Life in Nursing Homes: A Critical Ethnography," in The Worth of Women's Work, ed. Anne Statham, Eleanor M. Miller, and Hans O. Mauksch (Albany: SUNY Press, 1988). 28. Bonnie Bullough," Role Expansion: The Driving and Restraining Forces," in The Law and the Expanding Nursing Role, ed. Bonnie Bullough (New York: Appleton-Century Crofts, 1980). 29. Timothy Diamond," Social Policy and Everyday Life," 48. 30. Royal Australian Nursing Federation, " Introduction," 3. 31. Jane Gaskell, " Conceptions of Skill." 32. Patricia Benner, From Novice to Expert: Excellence and Power in Clinical Nursing Practice (Menlo Park, CA: Addison-Wesley, 1984). 33. A.H. Stromberg, " Women in Female Dominated Professions," in Women Working: Theories and facts in Perspective, 2nd edition, ed. A. Stromberg and S. Harkness (Mountain View, CA: Mayfield, 1988). 34. P. Bellaby and P. Oribabor," Determinants of the Occupational Strategies adopted by British Hospital Nurses," International Journal of Health Services 10,no.2,291-309.

Nurses and Patient Information Technology / 87 35. G. Briscoe, " Computers: Past, Present and Future/' in Royal Australian Nursing Federation, Computerized Patient Data and Nursing Information Systems. 36. K. Schultz, " Facing the Future: How Today's Events Will Impact on Tomorrow's Nursing/' R.N.A.O. News, Fall 1988. 37. Campbell, " Productivity in Canadian Nursing." 38. K. Desborough, " Infostat," 13-14. 39. Ibid., 19-20. 40. Ibid. 41. Campbell, " Productivity in Canadian Nursing."

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The Unionization of Nurses Elaine Day

Introduction

Registered nurses, trained according to Florence Nightingale's idealized conception of the nurse as a proper "lady," mother, and wife, have in the past been a conservative group. As recently as 1974, when 150 of 180 nurses at Northwestern General Hospital in Toronto went on "strike/7 Anne Gribben, director of the Registered Nurses' Association of Ontario, initially responded: "It's a measure of my self-image as a nurse that to find some of our girls [sic] had actually done it, just walked out, was quite staggering/'1 Staggering though it may have been to Gribben and others, the effect of the one-day walkout was nation-wide. Within weeks forty-nine of Ontario's larger hospitals had met nurses' demands for an eighteen month contract containing a 45 per cent raise. Although she officially deemed the nurses' action "irresponsible," Gribben later admitted "I could sympathise. Most nurses in Canada have been treated so badly for so long there was bound to be an explosion somewhere. That walkout made hospitals, governments and the medical establishment realize nurses were not going to put up with any more." Not only did nurses endure pay lower

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than that of secretaries, teachers, cocktail waitresses, garbage collectors, and hospital cleaners; they also often worked twelve to fourteen consecutive days on shift. Hospital control over nurses was so complete that staff at Toronto's Queensway Hospital were forbidden to wear pantsuit uniforms.2 Women have a long association with healing, but the history of healing documents the subordination of women to men as healers. By the nineteenth century, men had successfully appropriated the "curing" function, leaving women the "caring" role.3 The close association between medicine and the ideology of a male-dominated society has had many crippling effects on nursing. The sexual division of labour is justified by the belief that it is a natural division. Journals published at the turn of the century provide examples of this belief. "The best nurse is that woman whose maternal instincts are well developed... .The connection between mothering and nursing is very close."4 That nursing should be so closely allied with mothering reinforces an ideology which portrays its most central relationships as mirror images of the patriarchal family. Its femaleness and close ties to the hospital have been the chief characteristics of nursing since its origins as an occupation. Alice Baumgart maintains that although history books suggest hospitals grew because of scientific advances, in fact prior to World War Two, a major factor permitting the expansion of hospitals in Canada was probably cheap student labour provided by hospital training programs for nurses. Hospitals used students not only to provide most of the nursing, dietary and housekeeping services of the hospital, periodically it sent them out to nurse in homes and so earn extra money for the institution. Hospitals for all their nobility, have been one of the most exploitative social institutions in the 20th century, both in terms of harming patients and in the oppression of workers.5

Relatedly, nurses are not considered to be especially skillful or knowledgeable. This was amply demonstrated in the May 1983 Grange Royal Commission into deaths at the Hospital for Sick Children. Male doctors were seen as having more expertise than female nurses. One of the basic reasons for the different treatment that women received throughout the Commission proceedings is their lack of social recognition as "rightful knowers." Genevieve Lloyd has noted that, since the time of Plato, knowledge and reason have been considered "male." She argues that the "maleness of the Man of Reason...lies deep in our philosophical tradition" and that in our quest for rational knowledge, male characteristics have been associated "with a clear, determined mode of thought, femaleness with the vague and indeterminate."6 Sandra Harding has described what she terms the difference in the distribution of rationality:

The Unionization of Nurses / 91 Women have been claimed less capable of abstract and systematic thought than men, less capable of developing a mature sense of justice than men, more ruled by the emotions, the passions and the appetites than men, and more inclined toward subjective assessments and less toward objective ones than men... rationality consistently has been attributed to women.7

Baumgart is more blunt in her assertion that "when push comes to shove, the nurse tends to get treated like any other piece of technical equipment. This is illustrated in a report of the Ontario Council of Health just over a year ago, where nurses were listed, along with plastic pill counters as just another means of improving compliance among hypertensives/7 Moreover, Baumgart notes, the majority of physicians and hospital administrations throughout nursing history have ''been primary advocates of the 'born nurse' theory, that the best nurse is somebody who is a little bit stupid but pleasant".8 This is absurd considering that it is the nurses who are with the patients twenty-four hours a day, and if a mistake is made the nurse is held responsible. It is little wonder, therefore, that nurses have become more vocal in their demands and joined unions in the hope they would receive more recognition as professional workers, salaries comparable to their worth, and some control over working conditions. Not all of these concerns have been met, although nurses who belong to unions, as in most other job categories, are better off than their non-unionized sisters. Many of the conditions shared by nurses were part of a larger trend faced by the growing numbers of women in the labour force. It is the purpose of this paper to examine women and the union movement, the unionization of nurses in Ontario and the effects an increasingly cohesive neoconservative state apparatus has had in setting back the hard-won victories of these public-sector workers. Women and the Union Movement The majority of women workers in Canada do not belong to unions. In 1927, only one woman out of one hundred working outside the home belonged to a union, and this ratio remained the same throughout the Depression. But as a result of war production, a larger percentage of women entered the workplace. By 1940, of 307,000 women in the labour force, 23,170 were organized.9 Unionization rates grew more rapidly in the postwar period. Anticipating high levels of unemployment among women in the post war period and fearing that women would compete with men for scarce jobs, the government sought answers from an Advisory Committee on Reconstruction. Pat Armstrong summarizes the state's solution to unemployment levels among women.

92 / Vital Signs The final report...(1944) suggested the problems could be solved by (a) marriage, (b) opportunities for women on the farm, (c) positive expansion in household work if conditions improved, (d) new government services such as health insurance, (e) expansion in the distributive trades and service occupations, and (f) new industries such as the manufacture of plastic and household gadgets. Thus the state explicitly acknowledged the interpenetration of domestic and wage labour.10

The government adopted a Keynesian approach to the regulation of the economy, introducing unemployment insurance and social welfare programs and controlling wages and inflation levels. As a result, the economy grew rapidly and the state sector became a major employer. By 1980, five of the six largest unions in Canada represented public service employees, a large percentage of whom were female health, educational and clerical workers.11 These organized women, not surprisingly, received higher wages than non-unionized women workers. Julie White12, in Women and Unions, demonstrated that unionized women received on average 14 per cent more than those who were not unionized, while unionized men received 8 per cent more than those who were not unionized.13 Meanwhile, however, the majority of women remain trapped in low-paying, semi-skilled, routinized jobs. Women's limited involvement in the union movement may be attributed to several factors. First, much misinformation still surrounds union activity. Many people have the impression that unions are run by ruthless American Mafia-type leaders—what Grace Hartman calls the "Hoff a syndrome"—and that unions automatically mean strike action. Yet, as Hartman point out, 95 per cent of collective agreements are settled without strike action, a fact seldom reported by the mass media. Second, the sexism of our society is reflected in the union movement. Even in the workplaces covered by collective agreements negotiated by government, large wage gaps between male and female workers remained. For example, in the health-care system, male orderlies, who receive on-the-job training, were paid more than the mainly female registered nursing assistants who receive specialized training for one year. Orderlies, being male, were considered "heads of households" and therefore entitled to a higher wage. Third, employers often work to restrict unionization. Fourth, because women work both within the home and in wage work, they may have limited time to spend in union activity. If meetings are held at night, for example, they must worry about additional child-care, unsafe transportation, and getting food on the table. Fifth, one in four women works part-time. Part-time workers' contact with each other is limited, and thus so are their opportunities to discuss their work problems and to do something about

The Unionization of Nurses / 93 them. Finally, in times of high unemployment, women may fear losing their jobs if they become involved in unionization.14 Patricia Marchak15 has argued that unions as they are presently constituted are not much help to most white-collar women workers and that an effective solution might well be unions composed solely of women. In fact, women have made the most significant gains in those unions in which they are the majority. By the early 1980s, 68.5 per cent of all women union members belonged to unions in which they made up between 30 and 70 per cent of the membership. Slightly more than 17 per cent of female union members were represented in traditional areas of female employment, such as nursing. Therefore, more than 80 per cent of organized women belong to unions with at least a 30 per cent female population.16 But even in these women's unions, gains for women have been difficult to achieve. The work most women do in the public sector is an extension of traditional "women's work"—caring for the sick, cleaning, serving and preparing food, and looking after children. When women do go on strike, particularly if it is an illegal strike, the media depict them as workers who have abandoned sick and dying patients, left children unattended, and caused students to repeat their school year. Women, trained to be responsible, are made to feel guilty. Hospitals have regularly laid off workers and eliminated jobs, with the result that hospital emergency rooms are overcrowded and surgical waiting lists are growing longer. Yet when women leave their jobs to protest such conditions, the state declares their services "essential," and the media blame the women for lack of care. Thus the public has, generally, a dim view of public-sector workers who strike.17 By the late 1970s, the majority of women union members were in public-sector unions and worked in some capacity for the state. During this period, many among this group won the right to strike, and many of them made significant gains as a result. As Armstrong18 points, out "teachers and nurses" were especially successful at "achieving increased wage rates as well as job security clauses." These gains were, of course, not won overnight or without some contradictory results for women. This article examines this long struggle, looking at Ontario as one example of nurses' efforts to organize and to alter their conditions of work, and at the Alberta nurses' strike as an indication of nurses' growing militancy in modern terms, even as the state increasingly seeks to control them.

The Unionization of Nurses in Ontario As of June 1988, the Ontario Nurses Association was the collective bargaining agent for registered nurses in 187 hospitals in Ontario.19 Collective bargaining of nurses in this province did not commence formally until 1966.

94 / Vital Signs As early as the turn of the century, however, nurses trained in hospitals formed alumnae groups. By 1904, these groups had formed the Graduate Nurses' Association of Ontario. The association's primary goal was to obtain professional control over registration of nurses. They achieved this and successfully maintained it until the 1922 Nurses Act placed control over registration in the hands of a cabinet member, the Provincial Secretary. The tide turned again when a Council on Nurses Education, with nurses as members, was initiated four years later. A further act, in 1944, allowed for the appointment of a Director of Nurses' Registration and gave the Council power to make recommendations to the Health Minister regarding discipline cases.20 During the 1920s the Registered Nurses' Association of Ontario (RNAO) was founded as the voluntary professional organization representing both supervisory and staff nurses. Today it is affiliated with the Canadian Nurses Association. A1951 Act gave the RNAO board of directors the powers to regulate education, examinations, registration and the disciplining of nurses. In 1962 the College of Nurses was created to include all of Ontario's registered nurses. It was given the responsibility of supervising schools of nursing, registration, and disciplinary functions previously handled by the RNAO board of directors. Thus the College presided over self-regulating functions and the RNAO carried out other professional functions, including bargaining. Provincial associations, at the time, could not be certified in any provinces except British Columbia. The associations therefore had important roles to perform on behalf of their nursing membership.21 The issue of collective bargaining was encountered by public health nurses in Toronto during the early 1940s when they were approached by representatives of the American Federation of Labour. The RNAO turned the problem over to the Canadian Nurses Association, who in 1943 appointed a committee to "investigate the methods of collective bargaining, the relationship of nurses with trade unions, and federal and provincial labour regulations affecting nurses."22 Although the principle of collective bargaining was approved, trade unions were not felt to be the appropriate bargaining vehicle for nurses. For the CNA, "not only was the aggressive bargaining needed in negotiation seen as unladylike and unprofessional, there was a fear that unionization would lead to nurses' strikes." Collective bargaining thus fell to the provincial associations, establishing a fundamental aspect of nurses' policy: that collective bargaining for nurses should be carried out by nurses. Acting on the mandate from its parent organization, in January 1945 the RNAO created two committees, the Advisory Committee to Local

h

Nursing Groups and the Committee on Labour Relations. The Advisory Committee "was charged with advising nurses in difficulties with their employment agencies, pointing out to the employers the professional standards involved and endeavouring to bring about conferences on the matter under dispute/'23 The Labour Relations Committee examined the implications of collective bargaining on nursing as a profession and identified three possible options: 1) affiliate with a labour union 2) form a nurse's union 3) develop a professional plan to provide collective bargaining24

The RNAO, in accordance with the CNA, opposed the idea of seeking affiliation with existing trade unions, believing that trade unions would be incapable of appreciating the special needs and demands of the nursing profession. The second proposal was also rejected. The formation of a separate nurses7 union was thought premature "because the problem does not seem great enough to warrant such a course of action but mainly because it could result in a cleavage in the professional organization.77 Consequently, the committee recommended the third option, which would include the hiring of a "nurse consultant77 who would develop expertise in labour relations and advise local groups. It was this action "which set the course for collective bargaining practice for nurses for almost twenty years.7726 In 1948, the RNAO submitted a brief to the Ministry of Health recommending that it assist nurses by endorsing and recommending good personnel policies in all hospitals. The RNAO would provide a list of minimum practices and salaries to be presented to employers, emphasizing that these were not demands but rather recommendations.27 By 1950, the RNAO had distributed its set of approved personnel policies to all members and all known employers of registered nurses. Until 1958, these policies were reviewed annually. The nursing consultant suggested in the 1945 proposals was never hired. By 1953 there was an "increased tendency77 for nursing groups to consult the Labour Relations Committee. As a result, Dr. Kenneth Gray, RNAO legal counsel, was requested to retain an authority on labour law. However, this person was "unable to act77 and consequently the Association chose to "meet each situation as it arose.7728 The RNAO remained opposed to existing trade unions attempting to recruit nurses, repeating their stand that nurses should only be involved in associations with other nurses and that trade union membership could place nurses in a strike position. A no-strike position had been adopted by the Canadian Nurses Association in 1946 and approved by the RNAO,

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which opposed "strike action by nurses at any time for any cause." This reflected the conservatism which remained at the core of the profession. The membership supported the no-strike position. Nurses successfully persuaded civic employees not to include them in a bargaining unit at Hamilton General Hospital in 1948 and 1949. In 1952, nurses in Ottawa's Public Health Department "resigned en masse" when faced with a certification vote. Two years later, at Ottawa General Hospital, nurses voted unanimously against inclusion in a non-professional union. At Newmarket's Greenacres Home for the Aged, six nurses, when faced with a similar situation, resigned on principle.30 This recurring issue of union membership prodded the RNAO to reexamine its collective bargaining position. Because members were fearful of being forced to join a union against their wishes, the RNAO submitted a brief to the provincial government requesting exclusion from the Ontario Labour Relations Act. The legislature refused the Association's request. At the RNAO's 1958 annual meeting, several strategies were presented for discussion. Delegates ultimately chose a plan encouraging voluntary negotiations, following an established method used by the province's teachers. The new approach was "based upon more vigorous action by local groups, more systematic and expert assistance from the RNAO, and moral suasion as a last resort." The Annual Report of the Committee on Legislation and By-laws envisaged the following as a typical procedure for "voluntary negotiation": 1) Local groups of registered nurses formulate and present requests. 2) If no government action or refusal to meet by employer, intervention of theR.N.A.O. 3) Assistance by R.N. A.O. negotiator in preparing requests and setting up meetings. 4) If continuing refusal to meet or reach agreement by employer, the pressure of public opinion to be invoked.31

After its review period, the very limited success of this system was recognized even by the RNAO. "By 1961, it was quite obvious that many employees chose to ignore communications from their own staff and the RNAO....The voluntary relinquishment of the strike weapon was not always exerting a strong enough moral obligation on employers to deal fairly with nurse employees."32 Five years after the constitution of the above proposals, the Male Nurses' Committee called upon the RNAO to again review the question of collective bargaining. Accordingly, Professor John Crispo was approached by the RNAO to consider the various options open to nurses. He submit-

The Unionization of Nurses / 97 ted a report which was presented to the 1963 annual meeting. Crispo's opinion was that nurses are left in an unenviable position when it comes to the matter of bettering the conditions of their profession. In so far as this entails dealing with employers, [nurses] are really left with a form of begging rather than bargaining rights.33

The Crispo report recommended that nurses seek legislation providing them with compulsory arbitration. The Association's 1964 annual meeting overwhelmingly endorsed this proposal. A committee on collective bargaining was struck and the following year made attempts to achieve legislative changes for compulsory bargaining to be put into effect. A brief was presented to the Minister of Health outlining the Association's feeling that the Ontario Labour Relations Act was an unsuitable vehicle for nurses because of its strike mandate. Moreover, there was no provision in the Act for nurses employed in a managerial role. The nurses proposed instead the Nurses' Collective Bargaining Act of 1965, which included a system of voluntary arbitration and of separate units for managerial nurses. The RNAO was to act as the bargaining agent for both groups. These suggestions were presented to the membership and "nearly all of the 1,260 nurses registered on the first day [of the annual meeting] marched on the legislature in support of its implementation/'34 Within the RNAO, however, was a small but vocal group representing staff nurses who opposed the policies of their parent organization. Known as the Committee for the Advancement of Professional Nurses, their activity created controversy within the Association's membership. The group disbanded voluntarily in 1966, believing that they had achieved their aim of increasing awareness of the importance of collective bargaining. The government did not respond immediately to the nurses' demands. "The government cannot put nursing or any other group in an insulated or isolated compartment and deal with it as such," stated the Minister of Health.35 He offered no official reason for his opinion. Suggestions were forthcoming that the small group of dissidents within the association indicated nurses themselves were not in agreement on the collective bargaining issue. Since membership was on a voluntary basis, the RNAO could not technically speak for all nurses. The 1965 annual meeting decided not to wait for government direction but to begin collective bargaining "in any way deemed advisable" under the Ontario Labour Relations Act. Hence, by the summer of 1965, The R.N. A.O. stood ready to assist any group of nurses who were ready to organize themselves in a serious fashion for collective bargaining. At first

981 Vital Signs progress was not rapid. There were irritating legal obstacles. R.N. A.O. staff were as yet inexperienced. Many rank and file nurses still question the compatibility of their status as professionals with collective bargaining.36

Nurses' dissatisfaction began to be translated into action. At the end of 1965, Halton County public health nurses made an unsuccessful bid for certification. The following year, nurses at Riverview Hospital in Windsor achieved certification, becoming the first such group to win their rights before the Labour Relations Board. Composition of the bargaining unit remained in dispute because the hospital was opposed to including any nurse with managerial duties. The RNAO preferred to include as many nurses as possible in the unit. Meanwhile, the Province chose to ignore the findings of its own board of inquiry, the Bennett Commission. The Commission had recommended legislation that would grant the Cabinet "the discretion to prevent or end work stoppages by imposing compulsory arbitration in cases where either adequate patient care was threatened by stoppage or where one of the parties had not bargained in good faith and the other had requested arbitration/'37 Rather, the province established the Hospital Labour Disputes Arbitration Act (HLDA). Hospital nurses were to be organized under the Labour Relations Act, but disputes were to be settled by mechanisms within the HLDA. Accordingly, strikes were prohibited by law, compulsory arbitration being the alternative. Between 1967 and 1973, twenty-seven arbitration hearings of this type were held. By 1966, certifications of nurses had occurred in six public health units and two hospitals. By 1972, more than seven thousand nurses belonged to ninety bargaining units.38 Nurses, however, were exceedingly unhappy with the defined arbitration process. It caused time-consuming delays, none of the awards were retroactive, and arbitrators invariably used prior awards as guidelines. Nurses whose contracts were settled earliest saw their settlements used as standards for future cases, resulting in a pattern of no growth. In 1967, the creation of a Nurses' Central Security Fund brought together the resources of existing independent associations, and a more centralized coordination of collective bargaining began. By 1973, the Central Security Fund members and members of all associations had formed a constitutional committee to establish a new organization that would centralize the more than one hundred existing associations. Thirteen thousand nurses were, at the time, represented by one hundred and four nurses' associations. The RNAO was contracting out services for union purposes and was paid by the Central Security Fund. The move for centralization had the support of the membership, and the RNAO entertained the possibility of becoming the central body. The

The Unionization of Nurses / 99 Ontario government, however, would not pass legislation to enable the RNAO to negotiate, nor would it change the Ontario Labour Relations Act to allow nurses to bargain provincially. At its 1973 meeting the RNAO discussed why it could not be certified under the Labour Relations Act as a union. Cassidy and Hayes summarize the Association's reasons: (l)RNAO only allows registered nurses as members. The Ontario Labour Relations Board had already determined that both graduate and registered nurses were an appropriate bargaining unit. The RNAO itself did not wish to change, to admit graduate as well as registered nurses. (2)RNAO included all levels of registered nurses in its membership, directors, supervisors, etc. Thus there was a heavy involvement in RNAO by people who would be excluded by The Labour Relations Act as managerial. The RNAO's position was that while it did wish to assist in establishing a central body, it did not want to shut off higher levels of managerial nurses from its own membership.39 The RNAO, therefore, could not act as the central bargaining unit for nurses. It published a position paper outlining these reasons for uniting under one central body: (l)to remove administrative difficulty in dealing with numerous independent associations, (2)to provide a forerunner for provincial, central or regional bargaining, (3)to integrate bargaining objectives and strategies to prevent local groups from entering unfair agreements which might set a trend in the province, hamstringing the efforts of other bargaining units, (4)to provide the ability to exert increased pressure on the government, (5)to facilitate improved communication across the province, (6)to promote consistency in collective agreement language, (7)to simplify approaches to the OLRB. Presently, each independent nurses7 association must prove its status as a trade union before the Board.40 The membership favoured these proposals, and in October 1973 the Ontario Nurses Association (ONA) was formed. Its constitution was ratified by three hundred representatives of one hundred and three individual nurses' associations.41 After hearing the ONA's request for trade union status, the Ontario Labour Relations Board granted the certification in January 1974. Existing locals applied to merge with the ON A, and by the end of the year seventy new units were organized. The newly formed organization hired the existing RNAO Employment Relations Department and worked from a Toronto location. The people in the department had the experience of collective bargaining, and it seemed logical that they should form the core of the new body.

1001 Vital Signs As the ONA grew rapidly, so did its staff. Today, in addition to negotiators, there are also departments of communication, research, continuing education, finance, and management information systems, as well as a department of Human Resources. The headquarters remain in downtown Toronto, and there are also negotiators working out of regional offices in Thunder Bay, Hamilton, London, Ottawa, Sudbury, Timmins, and Kingston. There is a satellite office in Windsor. The ONA is a trade union and is composed exclusively of nurses. It includes both graduate and registered nurses, despite the RNAO's opposition to the inclusion of graduate nurses. Registered nursing assistants have, at various times, requested membership in the ONA, but without success. Also excluded by the ONA are (a) nurses in psychiatric hospitals who are represented by CSAO (now OPSEU) under the Crown Employees Collective Bargaining Act, (b) public health nurses in Toronto who are members of the Canadian Union of Public Employees (CUPE), (c) nurses at the Workers' Compensation Board Hospital and Rehabilitation Centre and at Toronto's Riverdale Hospital who are represented by CUPE, (d) Collingwood General and Marine Hospital nurses, who are organized by the Service Employees International Union (SEIU), (e) nursing instructors, who, with the transfer of nurse training programs to community colleges, belong to CSAO (OPSEU). The Ontario Labour Relations Act determines which nurses are included in and excluded from the bargaining unit. Also excluded from the unit are those in managerial positions, including hospital directors, associate directors, supervisors and head nurses. The certification of the ONA as the bargaining agent for nurses meant the process of centralized bargaining between hospitals and nurses could take place by the summer of 1974. Both the ONA and the Ontario Hospitals Association (OHA) were very much in favour of such action: ONA wished to achieve uniform conditions for nurses across the province. The OHA wanted to prevent ONA from using whipsawing tactics.... [Hence], two successful rounds of central bargaining took place, involving 40 hospitals in 1974 and 104 in 1975.42

By the summer of 1974, the ONA had participated in three arbitration hearings and was faced with the possibility of approximately forty-seven further arbitrations, all of which involved large Ontario hospitals. Earlier, CUPE had settled with several Toronto hospitals through central bargaining and this had a significant impact on the ONA. The ONA did not wish to incur the delay which would be inevitable if all forty-seven contracts ended in arbitration. The situation was further complicated by a wildcat strike in May of that year at Northwestern General. The ONA requested a mid-June meeting to discuss the possibility of central bar-

The Unionization of Nurses / 101 gaining. Representatives of ONA locals met in advance of the June meeting to determine their demands. The major demand was a 50 per cent wage increase for nurses in order to restore the traditional R.N.-R.N.A. differential. The scheduled meeting ended with the settling of several technicalities, but little else, before talks broke off. Nearly a month later, nurses in arbitration at Ottawa Civic Hospital were granted a 50 per cent monetary increase over a two-year period, thereby setting a pattern for the other hospitals. Of the forty-two hospitals by then engaged in the central bargaining process, all initially rejected the award. Eventually they settled on a contract which closely resembled Ottawa's. An additional thirty-three hospitals accepted the Ottawa decision, and by June of 1975 ninety-seven hospitals had collective agreements with their nursing staff. Another significant event in 1974 was the provincial government's establishment of a Hospital Inquiry Commission to ascertain the state of collective bargaining in the hospital sector. Hearings were held under the direction of Professor D.L. Johnston, and his report was published in November 1974. With respect to nurses, the most significant finding was the proposal to move towards a system of province-wide bargaining. The Commission recommended that, if the parties could not reach agreement, the province impose settlement on them. The ONA, of course, preferred voluntary arbitration. The Report, was "allowed to die/' however, and it is used today only as a reference point by unions seeking certain changes. The importance of the Johnston inquiry lay in the fact that it caused the Ontario Hospitals Association to reconsider its approach to collective bargaining. Accordingly, in 1974, it established the Employee Relations Policy Committee (ERPC) to encourage central bargaining. It created three steering committees of hospital representatives to coordinate central bargaining with nurses, paramedical workers, and service employees. Eventually, the Steering Committees merged to form a single standing subcommittee on bargaining. By 1983, two standing committees on collective bargaining evolved: one for nursing and paramedical personnel, the other for service workers. It was hoped that centralized bargaining would avoid wage differentials throughout the province, and that government would only have to negotiate with one agency, the ONA. By 1976 the creeping process of centralized bargaining between the ONA and the hospitals had broken down. Both sides agreed that monetary terms should be dealt with centrally, as individual hospitals have no real financial autonomy but are very largely dependent on annual government grants, the level of which is set by the Ministry of Health. Beyond that, the employer side wanted to confine central negotiations to matters which had broad common application across the

1021 Vital Signs province, leaving to local bargaining all issues which were affected by differences in the size, organizational structure and operating characteristics of individual hospitals. ONA, on the other hand, preferred to have a wider range of matters negotiated at the central table, leaving less room for local variation.43

The two Toronto hospitals in negotiation that year were Wellesley and Mount Sinai. In the Wellesley case, the arbitration board chose to restrict itself to the particular conditions of that hospital and warned that its decision should not automatically apply to other hospitals. They did recognize the need for a "commonality of compensation" between hospitals. In the Mount Sinai arbitration, the Board deferred to the previous decision, indicating it was "loathe to upset the comparative base established by the parties and in the absence of distinguishing factors considers the Wellesley award to be of compelling weight."44 Two awards negotiated at Kingston General Hospital and Toronto General Hospital in the 1978-9 round of arbitration helped establish a trend towards two-year agreements. Both sides preferred two-year settlements because they meant that the seemingly endless rounds of negotiation need not be undertaken as frequently. The experiences of the period 1976-79 persuaded hospitals of the need to return to a system of central bargaining. They wanted to maintain some autonomy, but they also recognized that patterns set in any given round of arbitration became the basis for future agreements. In 1980, the parties were able to agree on the Memorandum of Conditions for Joint Bargaining as set forth in section 8 of the HLDA act. This memorandum, now a pivotal part of central negotiations, outlined items to be addressed in central, as opposed to local, bargaining. Issues not assigned to central bargaining remain within the parameters of local bargaining. Unresolved issues are put to an arbitration board which sits in several Ontario cities. By 1980,132 or 92 per cent of hospitals with some 24,000 unionized nurses45 participated in the central process. The process was interrupted in September 1982 when the provincial government announced the Inflation Restraint Act, which sought to impose salary limits on public employees. Throughout the duration of the Act, settlements were limited to a 9 per cent increase in the first year and a 5 per cent increase in the second year, in accordance with ceilings set by the government. When the Act was lifted in 1984, negotiations continued as they had previously. Central bargaining between the hospitals and the ONA now appears to be an ingrained process, although it remains voluntary The ONA has developed a process to determine as accurately as possible the views of its membership before bargaining begins.

The Unionization of Nurses/ 103 Before each round of central bargaining, O.N. A. sends a questionnaire entitled Have A Say to each and every member, to find out his or her expectations and priorities on a wide variety of issues. Answers to the questionnaire are given detailed statistical analysis. The results of that analysis, together with suggestions from staff members and committees, are used by O.N. A/s Joint Bargaining and Objectives Setting Committee to update a book of shortterm, medium-term and long-term bargaining goals entitled Focus on Bargaining Objectives. A large meeting on bargaining objectives is then held, attended by two or three representatives from each local union. Proposed changes are taken back to the locals and voted on. Those changes which receive enough support are incorporated into the Focus book, the revised version of which serves as the basis for ONA's position at the bargaining table.46

After such a long bureaucratic struggle, nurses hoped the central bargaining process would remain in effect and be used to its full advantage by both parties. But the state has wielded its coercive power against nurses, particularly against their right to strike. State Coercion and the Alberta Nurses' Strike of 1988 The rise of the New Right in the United States, Britain, and Canada, combined with the current global crisis of capitalism, has produced a number of fundamental changes in our society. As Leo Panitch points out, "one of the most important developments...is a restructuring of work, whereby changing processes of production, changing locations of production, changing job definitions and requirements, and changing relations between workers and managers at the point of production are all issuing a profound challenge to long established patterns/'47 Moreover, the state has responded to the crisis of capitalism all of which have had their most detrimental effects on women. Pat Armstrong48 outlines two of the state's responses: the creation of employment, mostly for men, and the introduction of restraint programs, which primarily affect women. Since women continue to earn less than men, wage restraint ensures that they remain trapped at the low end of the wage scale. Monetarist policies involve curtailing social services. This means budgets to schools, hospitals, and other institutions are slashed. These are areas that have traditionally employed large numbers of women. The servicesector industry, which includes the areas of health and education, had by the early 1980s employed a higher proportion of women than any other industry. Restraint programs result in larger numbers of women undertaking either volunteer work or part-time work. "There is every indication that this trend will continue as employers seek to save money,

104 / Vital Signs

during crises and good times, by paying people to work short hours without breaks or benefits, and as work becomes more readily learned and workers thus more easily replaced/'49 One of the most deleterious effects of budgetary restraints on nursing has been the introduction of management techniques. Ontario hospitals have been a target of government restraint since 1975. Marie Campbell has recounted how the Ontario government has sought the cooperation of hospital administrators in the introduction of techniques such as patient classification systems.50 In addition to these new methods of record-keeping and data collection, some hospitals have even placed computerized terminals at patients' bedsides. These new techniques do two things: they "bring nursing practice in relation with a professional discourse and bring nursing under managerial scrutiny in a new way" Campbell goes on to point out that the "documentary processes of corporate management" which she studies "provide the means by which nurses' actions are coordinated in such a way as to bring them into line with state policy, itself oriented to capitalist interests."51 Campbell argues that nurses are now being subjected to a new form of nursing managerialism and, further, that class relations are being injected into nursing practice as head nurses become middle managers whose job it is to ensure that nurses under their control comply with these new methods of record-keeping. Pat Armstrong argues that this process, and the increase of part-time work, means more work for less money because "women can work harder, at more difficult tasks, for short periods of time... .By decreasing the number of days patients stay in the hospital and by reducing the number of nursing assistants and other staff, the state is also intensifying women's labour because each patient requires more care and it is provided by fewer workers."52 All of these changes for nurses are taking place in an environment in which the rights of workers in general are being suppressed. Leo Panitch and Donald Swartz document the present "assault on trade union freedoms."53 Their book does not go far enough in its discussion of women in trade unions, but it does make crucial observations which apply to workers in general. They point out that in April 1987 the Supreme Court ruled that the Charter of Rights and Freedoms does not guarantee the right to strike. The process wherein almost one-third of organized Canadian workers lost their right to strike for two to three years began with Prime Minister Pierre Trudeau's public-sector wage controls. To Panitch and Swartz, this signalled the closing of the era of free collective bargaining and "the shift toward a more coercive, less consensual system of state-labour relations."54 Almost 68 per cent of Canadians now believe workers should have the right

The Unionization of Nurses / 105

to strike. That right, however, is being constantly eroded. For the first fifteen years after 1950, there were only six instances of back-to-work legislation implemented by the state, in the following decade and a half, there were fifty-one cases, half of them between 1975-79. Another forty-three measures followed in the 1980-87 period. This new reliance on back-towork legislation "was part of a broader pattern of developments, one which characterized the onset of a new era in state policy toward labour. What marked this transformation," say the authors, "was a shift from the generalized rule-of-law coercion, toward a form of selective, ad hoc, discretionary state coercion/'55 In the early 1980s, legislation in Ontario covered more than 565,000 provincial, municipal, and regional public servants, including those working in hospitals, nursing homes, and ambulance service.56 The strike of Alberta nurses must be understood within this context of crisis and restraint. The right to strike was taken away from Alberta nurses in 1983. Premier Peter Lougheed vowed that his government would use the "notwithstanding clause" (the Charter clause in which provinces can override federal legislation) to deny public-sector workers the right to strike. In an unprecedented majority decision, Supreme Court Justice Gerald LeDain ruled: The constitutional guarantee of freedom of association on 8.2(d) of the Canadian Charter of Rights and Freedoms does not include, in the case of a trade union, a guarantee of the right to bargain collectively and the right to strike....The rights for which constitutional protection is sought—the modern rights to bargain collectively and to strike, involving correlative duties or obligations resting on an employer—are not fundamental rights or freedoms.57

This did not stop approximately 11,000 nurses in Alberta from walking off the job in January 1988. The nurses voted overwhelmingly to strike despite threats of jail and fines. One of the most amazing aspects of the strike was the wave of public sympathy. During a year which witnessed unpopular strikes in post offices and railroads, union leadership had expected hostility from Albertans. Instead, phone-in programs and letters to local newspapers strongly favoured the nurses' action, despite allegations that the strike was causing inconvenience and discomfort to patients. Several explanations were offered for the reaction of the general public. First, there was dislike of the premier, who had been vacationing or otherwise neglecting his duties during times of crisis. Second, the nurses succeeded in portraying themselves as crusaders for higher standards of health care. The public perceived them as hard-working, underpaid professionals. The Liberal health critic admitted, "there's an enormous

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amount of sympathy for the nurses/' The union reported receiving one hundred calls per day, 95 per cent in favour, with some callers even offering to supply the nurses with coffee on the picket lines (in -30C weather) and others wondering what they could do to help the strikers. The public's response was even more startling when one recalls the hostile reaction to the!977 and 1982 hurses' strikes. Third, many Albertans were upset at the province's plans to build a $100 million hospital in Edmonton and an $18 million hospital in the town of McLennan, plus the $111 million already spent on a Calgary hospital whose doors had never opened. Finally, many citizens felt the government was unfair to strikers in general, particularly in the aftermath of the bitter 1986 strike at the Gainers meat-packing plant.58 Even some Conservatives found the premier's handling of the strike distasteful. During the nineteen-day strike, the United Nurses of Alberta (UNA), the nursing union, was twice found guilty of criminal contempt and fined $400,000. Approximately two hundred individual members of the UNA were charged with civil contempt, as were twenty-five locals. The nurses claimed victory and voted 5,327 to 1,118 to return to work, after the new collective agreement gave nurses wage increases of up to 10.9 per cent over twenty-seven months and improved several benefits. There were no cutbacks, despite the employer's original demand for a 3 per cent wage rollback, and no loss of seniority rights in layoffs. The nurses became eligible for workers' compensation and disability benefits. The average Alberta nurse's salary is now $30,000 per year.59 One of the most significant aspects of the strike was that a female-dominated union could take on a right-wing government and win. One month after the Alberta strike ended, Ontario Nurses Association chief executive officer Glenna Cole Slattery told an interviewer such a strike was possible in Ontario in the future, in spite of a three-year contract signed in 1988. Slattery called the Alberta strike "a human response to human injustice" and said that similar injustices continue in Ontario. She pointed to mandatory overtime, which forces some nurses to work two twelvehour shifts in a row; to the increased patient load: the fact that patients are older and sicker and thus require more care; to new technology that has placed further burdens on nurses; and to hospitals that have reduced their budgets by short-staffing nursing departments.60 Slattery knew what she was talking about. In January 1989, some fifty Metro Toronto nurses, complaining of stress and burnout, came off the night shift and marched to Queen's Park. Wearing signs which said "I worked while MPPs slept," the nurses demanded higher pay and complained that patients are suffering because nurses are overworked. One R.N. reported working four twelve-hour shifts in one week. The nurses

The Unionization of Nurses / 107

wanted their union contract renegotiated because of low pay, long hours, and increased patient loads as many nurses leave the profession. Further reports have revealed instances where at least half of all emergency rooms have been closed. One doctor claimed she called fourteen hospitals in order to have a seriously ill patient admitted; finally she drove the patient to the hospital in which she is on staff. The problems are attributed to a severe nursing shortage due to underfunding of the health-care system.61 Nurses play a crucial role. Hospitals and the public cannot function without them. Donald Swartz comments. "Contemporary research suggests that reductions in infant mortality, the best predictor of life expectancy, are most closely associated with improvements in living conditions and with larger expenditures on public health and on nurses, and that larger expenditures on physicians are associated with higher rates of infant mortality [emphases added] ,"62 Nurses are increasingly demanding that their crucial role be recognized and are increasingly fighting back in the face of strategies that limit their capcity to provide care. Conclusions The United Nurses of Alberta say that job vacancy rates in nursing have doubled since the Alberta nurses' strike. The South District Chair, Glen Fraser, "is convinced that the Alberta government's hidden agenda was to prepare the health care system for privatization and free trade. 'One has to come to the conclusion that they [the provincial government] want a crisis. The only way they are going to sell privatization in this province is to tell the public that health care is dangerous and inefficient/"63 Others believe that free trade will lead directly to privatization. Marjorie Cohen64 predicts that the health-care system will be affected by the trade deal, and that privatization is likely, as is increased contracting out and reliance on more part-time, rather than full-time, employment. Cohen argues that this is already occurring. In an attempt to reduce costs, hospitals are contracting out a whole range of jobs, right up to administrative positions. American management teams are likely to implement more of the managerial-style processes described earlier in this book. Moreover, since nursing costs make up almost half of all hospital costs, nursing has the potential to be hard hit. The future of women working in the state sector is bleak. When governments cut back in the public sector, it is women who suffer. Moreover, government restraint programs limit the membership of women in unions. State under-funding will decrease the number of women union members.65 A cursory examination of the economy reveals that jobs are growing fastest in non-unionized sectors. The tragic irony is that recent studies have shown that nursing shortages and/or financial restraints actu-

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ally increase hospital costs. Understaffing may lead to longer patient stays, and patients who do not get turned often enough or receive adequate skin care may develop complications such as pneumonia. One study66 examined two hospital units-one consistently short-staffed, the other more adequately staffed. In the understaffed unit, patients developed more complications and became more ill, and consequently they spent longer in hospital. Understaffing also leads to a higher burnout rate for nurses, causing them to change jobs more frequently, another cost burden to the hospital involved. Hiring more staff is thus less costly in the long run, a fact hospitals and governments have yet to realize. Finally, the rise of neoconservatism and the increase in state coercion tend to make those nurses staying in the profession even more militant, as the Alberta strike demonstrated. This, too, could place a larger financial burden on the state. This article has documented the long, hard-fought battle for unionization among women, particularly nurses. Free trade, increased conservatism, and slashes in hospital budgets all have a profound impact on nurses. Both the gradual development of a nurses' union in Ontario and the militancy of nurses in Alberta demonstrate that these women have abandoned the submissive stereotype and are no longer willing to see and be silent.

NOTES 1.

Allan Edmonds, "Nursing Power/' Canadian Magazine, November 16,1974, 3.

2.

Ibid.

3.

See Barbara Ehrenreich and Deirdre English, Witches, Midwives and Nurses: A History of Women Healers (Old Westbury, N. Y: Feminist Press, 1973); Elaine Day, "A Twentieth Century Witch Hunt: A Feminist Critique of the Grange Royal Commission into the Deaths at the Hospital for Sick Children/' Studies in Political Economy 24 (Autumn 1987).

4.

Quoted in Eva Gamarnikow, "Sexual Division of Labour: The Case of Nursing/' in feminism and Materialism: Women and Modes of Production-, ed. Annette Kuhn and Ann Marie Wolpe (London: Routledge and Kagan Paul, 1978), 117.

The Unionization of Nurses / 109 5.

Alice Baumgart," Professional Obligations, Employment Responsibilities and Collective Bargaining: A New Agenda for the 1980s" (Unpublished paper presented to the Labour Relations Division, Vernon, B.C., June 10,1980), 4.

6.

Genevieve Lloyd, The Man of Reason: ''Male" and "Female" in Western Philosophy (Minneapolis: University of Minneapolis Press, 1984), x, 3.

7.

Sandra Harding, "Is Gender a Variable in Conceptions of Rationality? A Survey of Issues," in Beyond Domination: New Perspectives on Women and Philosophy. ed. Carol C. Gould (Totowa, N.J.: Rowman and Allanheld, 1983), 43.

8.

Baumgart, "Professional Obligations, Employment Responsibilites and Collective Bargaining," 6.

9.

Bob Framington and Janet Lynn Stewart; "The Trade Union Movement: A Study of Female Participation of Union Executives" (Unpublished paper for Professor C. Yates, McMaster University, March 1988).

10. Pat Armstrong, Labour Pains: Women's Work in Crisis (Toronto: Women's Press, 1984), 50,51. 11. Paul Phillips and Erin Phillips, Women and Work: Inequality in the Labour Market (Toronto: Lorimer, 1983), 147. 12. Julie White, Women and Unions (Ottawa: Canadian Advisory Council on the Status of Women, 1980). 13. Phillips and Phillips, Women and Work, 131. 14. Grace Hartman, "Women and Unions," in Women in the Canadian Mosaic, ed. Gwen Matheson (Toronto: Peter Martin Associates, 1976), 246. 15. M. Patricia Marchak, "The Canadian Labour Farce: Jobs for Women," in Women in Canada, ed. Marylee Stephenson (Toronto: New Press, 1973), 209-11. 16. Linda Briskin, "Women and Unions in Canada: A Statistical Overview," in Union Sisters: Women in the Labour Movement, ed. Linda Briskin and Lynda Yanz (Toronto: Women's Press, 1983), 39. 17. Judy Darcy and Catherine Lauzon, "The Right to Strike," in Briskin and Yanz, Union Sisters, 176. 18. Armstrong, Labour Pains, 57-58.

1101 Vital Signs 19. Ontario Nurses Union, "Milestones in the History of the Ontario Nurses Association'' (Unpublished paper, ONA Research Department, Toronto, 1989). 20. Elizabeth McNab, A Legal History of the Health Professions in Ontario-, A Study for the Committee on the Healing Arts (Toronto: Queen's Printer, 1970), Chapter 5. 21. Janet Kerr, "Emergence of Nursing Unions as a Social Force in Canada/' in Canadian Nursing: Issues and Perspectives, ed. Janet Kerr and Jannetta MacPhail (Toronto: McGraw-Hill Ryerson, 1988), 213. 22. Mark Lichty, "Collective Bargaining and Nurses in Ontario Public Hospitals, 1942-1987: A Case Study" (Unpublished paper, Centre for Industrial Relations, Queen's University, 1987), 3-4. 23. C.M. Cassidy and J.K. Hayes, "Collective Bargaining by Professionals in the Public Sector: The Case of Nurses in Ontario" (Unpublished paper submitted to the Law School, University of Toronto, April 1975), 6. 24. Lichty, "Collective Bargaining and Nurses," 4. 25. Cassidy and Hayes, "Collective Bargaining by Professionals," 7. 26. Ibid., 6. 27. Ibid., 8. 28. Ibid., 8-9. 29. Lichty, "Collective Bargaining and Nurses," 6. 30. Cassidy and Hayes, "Collective Bargaining by Professionals," 10. 31. Lichty, "Collective Bargaining and Nurses," 8. 32. Ibid. 33. Ibid., 9. 34. Cassidy and Hayes, "Collective Bargaining by Professionals," 14. 35. Ibid., 15. 36. Ibid., 16.

The Unionization of Nurses /111 37. Lichty, "Collective Bargaining and Nurses/711. 38. Cassidy and Hayes, "Collective Bargaining by Professionals/' 17. 39. Ibid., 20-21. 40. Lichty, "Collective Bargaining and Nurses/' 19. 41. Ibid., 20. 42. Ibid. 43. Ibid., 26-27. 44. Ibid., 29. 45. Ibid., 31. 46. Ibid., 39-40. 47. Leo Panitch, "Capitalist Restructuring and Labour Strategies/7 Studies in Political Economy 24 (Autumn 1987), 131. 48. Armstrong, Labour Pains, 127. 49. Ibid., 79,130,132. 50. Marie Campbell, "Management as 'Ruling7: A Class Phenomenon in Nursing," Studies in Political Economy 27 (Autumn 1988), 30. 51. Ibid., 33. 52. Pat Armstrong, "Female Complaints: Women, Health and the State," (Unpublished paper, Vanier College, Montreal, 1986), 19. 53. Leo Panitch and Donald Swartz, The Assault on Trade Union Freedoms (Toronto: Garamond Press, 1988). 54. Ibid., 10. 55. Ibid., 31. 56. Ibid., 37. 57. Ibid., 57-58.

1121 Vital Signs 58. Geoffrey York, "Nurses Win PR Battle with Getty/' The Globe and Mail (Toronto), February 8,1988,1,5. 59. Cindy Barrett, "Ending a Bitter Strike," Maclean's, February 22,1988,26. 60. Carol Thomas, "Nurses' Strike Could Happen Here, Union Says," Hospital News 1, no.9 (March 1988), 4. 61. Matt Maychak,"Nurses in Protest for Higher Pay," Toronto Star, January 14, 1989, 1; and Andre Picard, "Overcrowding Regularly Closing Metro Emergency Rooms," The Globe and Mail (Toronto), January 18,1989, Al, A2. 62. Donald Swartz, "The Politics of Reform: Conflict and Accommodation in Canadian Health Policy," in The Canadian State: Political Economy and Political Power, ed. Leo Panitch (Toronto: University of Toronto Press, 1977), 335-36. 63. Penney Kome, "Alberta Reaps What It Sowed: After the Strike, A Shortage of Nurses," This Magazine 22, no.6 (December 1988), 6. 64. Marjorie Cohen, Free Trade and the Future of Women's Work: Manufacturing and Service Industries (Toronto: Garamond Press and Ottawa: the Centre for Policy Alternatives, 1987), 75-76. 65. Armstrong, Labour Pains, 170,176. 66. Arlene Babad, "Financial Implications of Understaffing," ON A Newsletter, August 1988,14.

Bibliography Abelson, Janet, Peter Paddon, and Claude Strohmenger. Perspectives on Health. Ottawa: Statistics Canada, 1983. Aberdeen, Lady. "Achievement of the National Council of Women." In The Proper Sphere, ed. Ramsey Cook and Wendy Mitchinson. Toronto: Oxford University Press, 1976. Adaskin, Eleanor. "Organized Political Action: Lobbying by Nurses' Associations/' In Canadian Nursing Faces the Future: Development and Change, ed. Alice Baumgart and Jenniece Larsen. Toronto: C.V. Mosby, 1988. Angus, Douglas E. "A Great Canadian Prescription: Take Two Commissions and Call Me in the Morning/' In Restructuring Canada's Health Service System: How Do We Get There From Here? ed. Raisa Deber and Gail Thompson. Toronto: University of Toronto Press, 1992. Armstrong, Pat. "Female Complaints: Women, Health and the State." Unpublished paper, Vanier College, Montreal, 1986.

114 / Vital Signs Armstrong, Pat. Labour Pains: Women's Work in Crisis. Toronto: Women's Press, 1984. Armstrong, Pat and Hugh Armstrong. The Double Ghetto: Canadian Women and Their Segregated Work. Toronto: McClelland & Stewart, 1984. Armstrong, Pat and Hugh Armstrong. Health Care as a Business: The Legacy of Free Trade. Ottawa: Canadian Centre for Policy Alternatives, 1991. Armstrong, Pat and Hugh Armstrong. "Sex and the Professions in Canada/' Journal of Canadian Studies 27, no. 1 (Spring 1992). Armstrong, Pat and Hugh Armstrong. 'Taking Women into Account: Redefining and Intensifying Employment in Canada." In Feminization of the Labour Force, ed. Jane Jenson, Elizabeth Hagen, and Ceallaigh Reddy. Oxford: Polity Press, 1988. Attewell, P. "The Deskilling Controversy." Work and Occupations 14, no. 3 (August 1987). Audette, Lise Marie, Jocelyne Carle, Angeline Simard, Charles Tilquin et collaborateurs. PRN75: Un Systeme d'information quantitative pour la gestion des soins infirmiers. Montreal: CSN, 1970. Babad, Arlene. "Financial Implications of Understaffing." ONA Newsletter, August 1988,14. Barrett, Cindy. "Ending a Bitter Strike." Maclean's, February 22,1988, 26. Bates, Erica and Helen Lapsley. The Health Machine. Ringwood, Australia: Penguin, 1985. Baumgart, Alice. "Address." Toronto: mimeo, 1985. Baumgart, Alice. "The Nursing Workforce in Canada." In Canadian Nursing Faces the Future: Development and Change, ed. Alice Baumgart and Jenniece Larsen. Toronto: C.V. Mosby, 1988. Baumgart, Alice. "Professional Obligations, Employment Responsibilities and Collective Bargaining: A New Agenda for the 1980s." Unpublished paper presented to the Labour Relations Division, Vernon, B.C., June 10, 1980.

Bibliography /115 Beechey, Veronica. "The Sexual Division of Labour and the Labour Process: A Critical Assessment of Braverman." In The Degradation of Work: Skill, Deskilling and the Labour Process, ed. Stephen Wood. London: Hutchinson, 1982. Bellaby, P. and P. Oribabor. "Determinants of the Occupational Strategies Adopted by British Hospital Nurses." International Journal of Health Services 10, no. 2, 291-309. Benner, Patricia. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley, 1984. Billette, Andre, avec la collaboration de Guy Frechet et Claude Labbe. L'Infirmiere et la systeme PRN. Quebec: CSN, 1982. Bilson, Geoffrey. "Canadian Doctors and the Cholera." In Medicine in Canadian Society, ed. S.E.D. Shortt. Montreal: McGill-Queen's University Press, 1981. Blishen, Bernard. Doctors in Canada. Toronto: University of Toronto Press, 1991. Braverman, Harry. Labor and Monopoly Capital: The Degradation of Work in the Twentieth Century. New York: Monthly Review Press, 1974. Briscoe, G. "Computers: Past, Present and Future." In Royal Australian Nursing Federation, ed. Computerized Patient Data and Nursing Information Systems: Some Considerations. South Melbourne: RANF, 1984. Briskin, Linda. "Women and Unions in Canada: A Statistical Overview." In Union Sisters: Women in the Labour Movement, ed. Linda Briskin and Lynda Yanz. Toronto: Women's Press, 1983. British Columbia, Royal Commission on Health Care and Costs. Closer to Home. Victoria: Province of British Columbia, 1991. Buckley, Susan. "Ladies or Midwives? Efforts to Reduce Infant and Maternal Mortality." In A Not Unreasonable Claim: Women and Reform in Canada, 1880-1920, ed. Linda Kealey. Toronto: Women's Press, 1979. Bullough, Bonnie. "Role Expansion: The Driving and Restraining Forces." In The Law and the Expanding Nursing Role, ed. Bonnie Bullough. New York: Appleton-Century Crofts, 1980.

116 / Vital Signs Butler, Irene, Eugenia Carpenter, Bonnie Kay, and Ruth Simmons. Sex and Status: Hierarchies in the Health Workforce. Michigan: American Public Health Association, 1985. CSN. Choisir. Montreal: mimeo, n.d. Campbell, Marie. 'Information Systems and Management of Hospital Nursing: A Study in the Social Organization of Knowledge/' Ph.D. thesis, University of Toronto, 1984. Campbell, Marie. "Management as 'Ruling': A Class Phenomenon in Nursing/7 Studies in Political Economy 27 (Autumn 1988). Campbell, Marie. "Productivity in Canadian Nursing: Administering Cuts/' In Health and Canadian Society: Sociological Perspectives, 2nd edition, ed. D. Coburn, C. D'Arcy, G. Torrance, and P. New. Markham, Ont.: Fitzhenry & Whiteside, 1987. Canada, Department of Labour. Women at Work in Canada. Ottawa: Department of Labour, 1964. Canada, Employment and Immigration. The Labour Market for Nurses in Canada: A Summary Discussion and Analysis. Ottawa: Employment and Immigration Canada, 1989. Canada, Health and Welfare. Health Personnel in Canada. Ottawa: Health and Welfare, 1988. Canada, Royal Commission on Health Services. Report, Volume 1. Ottawa: Queen's Printer, 1964. Canadian Advisory Council on the Status of Women. Integration and Participation: Women's Work in the Home and in the Labour Force. Ottawa: CACSW, 1987. Cassidy, C.M. and J.K. Hayes, "Collective Bargaining by Professionals in the Public Sector: The Case of Nurses in Ontario." Unpublished paper submitted to the Law School, University of Toronto, April 1975. Cayley, David. Doctoring the Family. Montreal: CBC, 1985. Clemenson, Heather A. "Unionization and Women in the Service Sector." Perspectives on Labour and Income 1, no. 2 (Autumn 1989).

Bibliography /117 Coburn, D., G. Torrance and J.M. Kaufert. "Medical Dominance in Canada in Historical Perspective: The Rise and Fall of Medicine?" International Journal of Health Services 13, no. 3 (1983). Coburn, Judi. "'I See and Am Silent': A Short History of Nursing in Ontario 1850-1930." In Women at Work: Ontario 1850-1930, ed. Janice Acton, Penny Goldsmith, and Bonnie Shepard. Toronto: Women's Educational Press, 1974; and in Health and Canadian Society, ed. D. Coburn, C. D'Arcy, G. Torrance, and P. New. Toronto: Fitzhenry & Whiteside, 1981. Cohen, Marjorie. Free Trade and the Future of Women's Work: Manufacturing and Service Industries. Ottawa: Garamond Press and the Centre for Policy Alternatives, 1987. College of Nurses of Ontario. Standards of Practice for Registered Nurses and Registered Nursing Assistants. Toronto: College of Nurses of Ontario, 1987. Cooperstock, Ruth and Harvey Lennard. "Role Strain and Tranquilizer Use." In Health and Canadian Society, ed. D. Coburn, C. D'Arcy, G. Torrance, and P. New. Toronto: Fitzhenry & Whiteside, 1981. Copps, Terry. "Public Health in Montreal, 1870-1930." In Medicine in Canadian Society, ed. S.E.D. Shortt. Montreal: McGill-Queen's University Press, 1981. Darcy, Judy and Catherine Lauzon. "The Right to Strike." In Union Sisters: Women in the Labour Movement, ed. Linda Briskin and Lynda Yanz. Toronto: Women's Press, 1983. Day, Elaine Buckley. "A Twentieth Century Witch Hunt: A Feminist Critique of the Grange Royal Commission on the Deaths at the Hospital for Sick Children." Studies in Political Economy 24 (Autumn 1987). DeBresson, Chris and Margaret Lowe Benston. "Introduction." In Work and New Technologies: Other Perspectives, ed. Chris DeBresson, Margaret L. Benston, and Jesse Vorst. Toronto: Between the Lines, 1987. De Konick, Maria, Francine Saillant et Lise Dunnigan. Essai sur la sante des femmes. Quebec: Conseil de statut de la femme, 1981. Desborough, K. "Infostat: A National Study on the Impact of Computers on Nurses." Ottawa: National Federation of Nurses' Unions. de Seve, Nicole, Diane Lamoureaux et Joelle Levesque. Femmes, infirmieres et si c'etait la meme histoire. Quebec: mimeo, 1984.

118 / Vital Signs Diamond, Timothy. "Social Policy and Everyday Life in Nursing Homes: A Critical Ethnography/' In The Worth of Women's Work, ed. Anne Statham, Eleanor M. Miller, and Hans O. Mauksch. Albany: SUNY Press, 1988. Direcks, Anita and Ellen 't Hoen. "DES: The Crime Continues/' In Adverse Effects: Women and the Pharmaceutical Industry, ed. Kathleen McDonnell. Toronto: Women's Press, 1986. Dominion Bureau of Statistics. Census of Canada: Labour Force. Ottawa: Queen's Printer, 1966. Doyal, Lesley. The Political Economy of Health. London: Pluto, 1979. Economic Council of Canada. Employment in the Service Economy. Ottawa: ECC, 1991. Edmonds, Allan. "Nursing Power." Canadian Magazine, November 16,1974. Ehrenreich, Barbara and Deirdre English. Witches, Midwives and Nurses: A History of Women Healers. Old Westbury, N.Y.: Feminist Press, 1973. Elger, T. "Braverman, Capital Accumulation and Deskilling." In The Degradation of Work: Skill, Deskilling and the Labour Process, ed. Stephen Wood. London: Hutchinson, 1982. Employment and Immigration Canada. The Labour Market for Nurses in Canada. Ottawa: Employment and Immigration Canada, 1989. Engelson, Barbara. Letter to Elenor Ross, President, Registered Nursing Association of Ontario, May 12,1988. Enterline, Philip E., }. Corbet McDonald, Alison D. McDonald, Lise Davignon, and Vera Salter. "Effects of Tree' Medical Care on Medical Practice: The Quebec Experience." The New England Journal of Medicine 288, no. 2 (1973). Evans, R.G. "Economic Perspective." In National Health Insurance: Can the U.S. Learn from Canada? ed. S. Andreopoulos. New York: Wiley, 1975. Flaherty, Josephine. Testimony in Ontario Nurses Association v Women's College Hospital, Sunnybrook Hospital and North York General Hospital, 1991. Framington, Bob and Janet Lynn Stewart. "The Trade Union Movement: A Study of Female Participation of Union Executives." Unpublished paper for Professor C. Yates, McMaster University, March 1988.

Bibliography /119 Gamarnikow, Eva. "Sexual Division of Labour: The Case of Nursing/7 In Feminism and Materialism: Women and Modes of Production, ed. Annette Kuhn and Ann Marie Wolpe. London: Routledge & Kegan Paul, 1978. Gaskell, Jane. "Conceptions of Skill and the Work of Women: Some Historical and Political Issues/' In The Politics of Diversity: Feminism, Marxism and Nationalism, ed. R. Hamilton and S. Barrett. Montreal: Book Centre, 1987. Gibbon, J.M. and M.S. Mathewson. Three Centuries of Canadian Nursing. Toronto: Macmillan, 1947. Goldfarb Corporation. The Nursing Shortage in Ontario: A Research Report for The Ontario Nurses Association. Toronto: ONA, March 1988. Hamner, J. and D. Leonard. "Negotiating the Problem: The DHSS and Research on Violence in Marriage/' In Social Researching: Politics, Problems, Practice, ed. C. Bell and H. Roberts. London: Routledge and Kegan Paul, 1984. Harding, Sandra. "Is Gender a Variable in Conceptions of Rationality? A Survey of Issues/' In Beyond Domination: New Perspectives on Women and Philosophy, ed. Carol C. Gould. Totowa, N.J.: Rowman and Allanheld, 1983. Hartman, Grace. "Women and Unions/' In Women in the Canadian Mosaic, ed. Gwen Matheson. Toronto: Peter Martin Associates, 1976. Jensen, Phyllis Marie. "The Changing Role of Nurses' Unions." In Canadian Nursing Faces the Future: Development and Change, ed. Alice Baumgart and Jenniece Larsen. Toronto: C.V. Mosby, 1988. Kerr, Janet. "Emergence of Nursing Unions as a Social Force in Canada." In Canadian Nursing: Issues and Perspectives, ed. Janet Kerr and Jannetta MacPhail. Toronto: McGraw-Hill Ryerson, 1988. Kerr, Janet. "Unionism and Professionalism: Conflicting or Compatible Processes?" In Canadian Nursing: Issues and Perspectives, ed. Janet Kerr and Jannetta MacPhail. Toronto: McGraw-Hill Ryerson, 1988. Kleiber, Nancy and Linda Light. Caring for Ourselves: An Alternative Structure for Health Care. Vancouver: B.C. Public Health, 1978. Kome, Penney. "Alberta Reaps What It Sowed: After the Strike, A Shortage of Nurses." This Magazine 22, no. 6 (December 1988), 6.

120 / Vital Signs Krahn, Harvey. Quality of Work in the Service Economy. Ottawa: Supply and Services Canada, 1992. Labour Canada. The Working Environment in Canadian Hospitals: Constraints and Opportunities. Ottawa: Labour Canada, 1984. Ladies of Toronto and Chief Cities and Towns in Canada. The Canadian Home Cook Book. Toronto: Hunter, Rose and Company, 1970. Lalonde, Marc. A New Perspective on Health of Canadians. Ottawa: Queen's Printer, 1974. Lapierre, Louise. Canadian Women: Profile of Their Health. Ottawa: Statistics Canada, 1984. Lee, Sidney. Quebec's Health System: A Decade of Change, 1967-77. Montreal: McGill University Press, 1979. Leeson, Joyce and Judith Gray. Women and Medicine. London: Tavistock, 1978. Lichty, Mark. "Collective Bargaining and Nurses in Ontario Public Hospitals, 1942-1987: A Case Study/' Unpublished paper, Centre for Industrial Relations, Queen's University, 1987. Light, Beth and Ruth Pierson, eds. No Easy Road: Women in Canada, 1920s to 1960s. Toronto: New Hogtown Press, 1990. Lloyd, Genevieve. The Man of Reason: "Male" and "Female" in Western Philosophy. Minneapolis: University of Minneapolis Press, 1984. Loughton, H.H., ed. A Gentlewoman in Upper Canada. Toronto: Clarke, Irwin, 1964. MacDonald, Eva and Elizabeth Webb. "A Survey of Women Physicians in Canada, 1883-1964." Canadian Medical Association Journal 94 (June 1966). McDonnell, Kathleen and Mariana Valverde. The Healthsharing Book. Toronto: Women's Press, 1985. Mackay, Relief. "Poor Relief and Medicine in Nova Scotia, 1749-1783." In Medicine in Canadian Society, ed. S.E.D. Shortt. Montreal: McGill-Queen's University Press, 1981. McKeown, Thomas. "Medical Technology and Health Care." In Doctors, Patients and Society, ed. M.S. Straum and D.E. Larsen. Waterloo: Wilfrid Laurier University Press, 1981.

Bibliography /121 MacMurchy, M. 'The Woman—Bless Her/' In The Proper Sphere, ed. Ramsey Cook and Wendy Mitchinson. Toronto: Oxford University Press, 1976. McNab, Elizabeth. Legal History of the Health Professions in Ontario. Study for the Committee on the Healing Arts. Toronto: Queen's Printer, 1970. Marchak, M. Patricia. 'The Canadian Labour Farce: Jobs for Women." In Women in Canada, ed. Marylee Stephenson. Toronto: New Press, 1973. Marsh, Leonard. Report on Social Security for Canada. Toronto: University of Toronto Press, 1975. Maychak, Matt. "Nurses in Protest for Higher Pay/' Toronto Star, January 14, 1989,1. Meissner, M. "Working Knowledge in the Office and the Household." Paper presented at CSAA Annual Meetings, Windsor, 1988. Montgomery, Randy. "Brief to Pay Equity Commission." Ontario, March 31, 1988. Montreal Health Press. Menopause: A Well Woman Book. Montreal: Montreal Health Press, 1990. Moskop, John C. "The Nature and Limits of the Physician's Authority." In Doctors, Patients and Society, ed. M.S. Straum and D.E. Larsen. Waterloo: Wilfrid Laurier University Press, 1981. Mussallam, Helen. "The Changing Roles of Professional Nurses' Associations." In Canadian Nursing Faces the Future: Development and Change, ed. Alice Baumgart and Jenniece Larsen. Toronto: C.V. Mosby, 1988. Myrtle, Robert and Juan Robertson. "Determinants of Job Satisfaction in Nursing Care Units." The Journal of Long-Term Care Administration 7 (Winter 1979). National Council of Women of Canada. Women of Canada: Their Life and Work. Ottawa: NCW, 1975. Navarro, Vincente. "The Crisis of the International Capitalist Order and Its Implications on the Welfare State." In Issues in the Political Economy of Health, ed. J.B. McKinlay London: Tavistock, 1984. Naylor, David. Private Practice, Public Payment. Kingston: McGill-Queen's University Press, 1986.

122 / Vital Signs Nichols, Grandma. The Great Nineteenth Century Medicine Manual. Toronto: Coles, 1978. Oakley, Ann. 'Interviewing Women: A Contradiction in Terms/7 In Doing Feminist Research, ed. Helen Roberts. London: Routledge & Kegan Paul, 1981. Oakley, Ann. Subject Woman. New York: Pantheon, 1981. Ontario, Ministry of Community and Social Services, Ministry of Health, and Ministry of Citizenship. Redirection of Long-Term Care and Support Services in Ontario: A Public Consultation Paper. Toronto: Ministry of Community and Social Services, 1991. Ontario, Premier's Council on Health Strategy. Nurturing Health: A Framework on the Determinants of Health. Toronto: Province of Ontario, 1991. Ontario Nurses Union. "Milestones in the History of the Ontario Nurses Association/7 Unpublished paper, ON A Research Department, Toronto, 1989. Panitch, Leo. "Capitalist Restructuring and Labour Strategies/7 Studies in Political Economy 24 (Autumn 1987). Panitch, Leo and Donald Swartz. The Assault on Trade Union freedoms. Toronto: Garamond Press, 1988. Pelrine, Eleanor Wright. Morgentaler. Toronto: Gage, 1975. Phillips, Paul and Erin Phillips. Women and Work: Inequality in the Labour Market. Toronto: Lorimer, 1983. Picard, Andre. "Overcrowding Regularly Closing Metro Emergency Rooms/7 The Globe and Mail (Toronto), January 18,1989, Al, A2. Prentice, Alison, Paula Bourne, Gail Cuthbert Brandt, Beth Light, Wendy Mitchinson, and Naomi Black. Canadian Women: A History. Toronto: Harcourt Brace Jovanovich, 1988. Price, John A. "Canadian Indian Families/7 In The Canadian Family, ed. K. Ishwaran. Toronto: Gage, 1983. Pryke, Kenneth G. "Poor Relief and Health Care in Halifax, 1827-1849." In Essays in the History of Canadian Medicine, ed. Wendy Mitchinson and Janice Dickin McGinnis. Toronto: McClelland & Stewart, 1988.

Bibliography /123 Rachlis, Michael and Carol Kushner. "Under the Knife/' The Globe and Mail Report on Business, October 1992, 88. Regush, Nicholas. Condition Critical. Toronto: Macmillan, 1987. Robertson, H. Rocke. Health Care in Canada: A Commentary. Background Study for the Science Council of Canada. Ottawa: Science Council of Canada, 1973. Royal Australian Nursing Federation. "Introduction/' In Computerized Patient Data and Nursing Information Systems: Some Considerations. South Melbourne: RANF, 1984. Schultz, K. "Facing the Future: How Today's Events Will Impact on Tomorrow's Nursing." R.N.A.O. News, Fall 1988. Smith, Dorothy and Sara J. David. Women Look at Psychiatry. Vancouver: Press Gang, 1975. Smith, Howard. "Quality of Working Life in a Health Maintenance Organization: Comparisons of Medical and Ancillary Personnel." Journal of Ambulatory Care Management 3 (November 1980). Soderstrom, Lee. The Canadian Health System. London: Croom Helm, 1978. Statistics Canada. Canada's Women: A Profile of Their 1988 Labour Market Experience. Ottawa: Statistics Canada, 1992. Statistics Canada. Canadians and Their Occupations: A Profile. Ottawa: Supply and Services Canada, 1989. Statistics Canada. Earnings of Men and Women, 1989. Ottawa: Supply and Services Canada, 1990. Statistics Canada, family Incomes: Census Families. Ottawa: Supply and Services Canada, 1992. Statistics Canada. Nursing in Canada, 1986. Ottawa: Supply and Services Canada, 1988. Statistics Canada. Women in Canada: A Statistical Report, 2nd edition. Ottawa: Supply and Services Canada, 1990. Stromberg, A.H. "Women in Female Dominated Professions." In Women Working: Theories and Facts in Perspective, 2nd edition, ed. A. Stromberg and S. Harkness. Mountain View, CA: Mayfield, 1988.

124 / Vital Signs Strong-Boag, Veronica. "Canada's Women Doctors: Feminism Constrained/7 In Medicine in Canadian Society, ed. S.E.D. Shortt. Montreal: McGillQueen's University Press, 1981. Sutherland, Neil. "To Create a Strong and Healthy Race': School Children in the Public Health Movement, 1880-1914." In Medicine in Canadian Society, ed. S.E.D. Shortt. Montreal: McGill-Queen's University Press, 1981. Swartz, Donald. "The Politics of Reform: Conflict and Accommodation in Canadian Health Policy." In The Canadian State: Political Economy and Political Power, ed. Leo Panitch. Toronto: University of Toronto Press, 1977. Taylor, Malcolm. Health Insurance and Canadian Public Policy. Montreal: McGill-Queen's University Press, 1978. Thomas, Carol. "Nurses' Strike Could Happen Here, Union Says." Hospital News 1, no. 9 (March 1988), 4. Torrance, George. "Hospitals as Health Factories." In Health and Canadian Society, ed. D. Coburn, C. D'Arcy, G. Torrance, and P. New. Toronto: Fitzhenry & Whiteside, 1981. Torrance, George. "Socio-Historical Overview: The Development of the Canadian Health System." In Health and Canadian Society, ed. D. Coburn, C. D'Arcy, G. Torrance, and P. New. Toronto: Fitzhenry & Whiteside, 1981. Torrance, George. "The Underside of the Hospital: Recruitment and the Meaning of Work Among Non-Professional Hospital Workers. In The Sociology of Work: Papers in Honour of Oswald Hall, ed. Audrey Wipper. Ottawa: Carleton University Press, 1984. Tunis, Barbara. "Medical Licensing in Lower Canada: The Dispute over Canada's First Medical Degree." In Medicine in Canadian Society, ed. S.E.D. Shortt. Montreal: McGill-Queen's University Press, 1981. Vancouver Women's Health Collective. A Vancouver Women's Health Booklet. Vancouver: Vancouver Women's Health Collective, 1972. Waterhouse, Linda. Letter to Barbara Engelson. Ontario Pay Equity Commission files, May 17,1988. Weisman, Carol, Cheryl Alexander, and Gary Chase, "Job Satisfaction Among Hospital Nurses: A Longitudinal Study." Health Services Research 15 (Winter 1980).

Bibliography /125 Wertz, Richard and Dorothy Wertz. Lying In: A History of Childbirth in America. New York: Schocken, 1979. White, Charles. "Where Have All the Nurses Gone—and Why?" Hospitals 54 (April 1980). White, Julie. Women and Unions. Ottawa: Canadian Advisory Council on the Status of Women, 1980. Whittaker, Jo Ann. 'The Search for Legitimacy: Nurses7 Registration in British Columbia, 1913-1935." In Not Just Pin Money, ed. Barbara Latham and Roberta Pazdro. Victoria: Camosun College, 1984. Wood, Stephen. "Introduction." In The Degradation of Work: Skill, Deskilling and the Labour Process, ed. Stephen Wood. London: Hutchinson, 1982. Wotherspoon, Terry. Immigration, Gender and Professional Labour: State Regulation of Nursing and Teaching. Paper presented to the Learned Societies meetings, Vancouver, 1990. Yalnizyan, Armine. "The Impact of Technological Change on Hospital Workers." Toronto: Service Employees International Union, Local 204, May 1986. York, Geoffrey. "Nurses Win PR Battle with Getty." The Globe and Mail (Toronto), February 8,1988,1, 5. Young, Gail. "A Woman in Medicine: Reflections from the Inside." In Women, Health and Reproduction, ed. H. Roberts. London: Routledge & Kegan Paul, 1981.