All About Bedpans: How Credentials Stratify Work

In a September episode of White Coat, Black Art,  host Dr. Brian Goldman attributes burnout among some young nurses to a gap between expectations established in pre-professional training, and the realities of the job. His guest, an early career ICU nurse, described this:

“Nurses really still seem to be in a secondary role to doctors, and I was surprised by the lack of respect that I felt as a nurse, and the stuff I was expected to do as a nurse that I didn’t get taught in nursing school.” The stuff she was expected to do included cleaning up bodily fluids (as the cleaning staff were not allowed to do this), cleaning bedpans, and answering the phone. “I feel like a glorified secretary sometimes,” she said.

This nurse, who at the time of the interview was considering a career change, also described having a great deal of responsibility, but little autonomy in the performance of her work. This is an issue well worth discussing on its own. But I’d like here to focus on what her comments suggest both about how our career expectations are shaped, and about, again, the question of status in the professions1.

First, consider the question of expectations. The nurse interviewed by Goldman recalled the idealism she developed through her nursing education: she described, briefly, feminist influences, and the idea that nursing profession was evolving professionally into realms of greater power and responsibility. Her work experience was rather far removed from what, through her education, she had been taught to expect.2

As college and university degrees are increasingly marketed in terms of “careers,” you have to wonder whether unmet, “great expectations” are also becoming more pervasive. Lots of unis and colleges are developing co-op programs to help bridge learning and practice, but I remain skeptical. It seems to me that once we start marketing education – a phenomenon that has really intensified in Canada in recent years – there can be a nasty, dark underbelly in terms of exploiting students’ (often uninformed and under-researched) aspirations. Does this contribute to unrealistic career expectations? I wouldn’t argue this as an absolute, but I do think it’s a question worth asking.

The second point I’d like to consider is a question that I’d love to put to health professionals. Does the increasing stratification of health care entrench, in some unhealthy and unexamined ways, a form of credentialed elitism? Perhaps I was tweaked to consider this by the nurse’s comments about cleaning bedpans. I couldn’t help but compare this to the stoically cheerful comments by my daughter’s stepmom, a long-practicing nurse, about shifts spent “wiping butts.” Have these two nurses – one newer, one with twenty years on the job – simply learned to think differently about the meaning of their work? Has our younger nurse been trained in an environment where it is expected that the lower status aspects of care will be “downloaded” onto LPNs and nursing assistants?3

It’s not a frivolous question. What I’m thinking about here is something akin to an unrecognized caste system, which is entrenched both through professionalization and, in many cases, unionization. Basically, the more thoroughly we are able to describe work – name positions and place boundaries around the nature of tasks that will and will not be performed – the more opportunity there is to segregate “good work” from “not so good work.”

Feminist accounts of work and learning (which have expanded, appropriately, to consider questions of race), point to the ways in which care of children (education, early childhood education and daycares/dayhomes), and care of the ill and infirmed (hospital and long-term care), are disproportionately assigned to society’s most disadvantaged (on average) members: women, immigrants, and visible minorities.

So as we continue to define increasingly specific forms of work through training and credentialing (dayhome providers, homecare providers, nursing assistants, etc.), some real problems emerge. One is that university degrees may “overqualify” those who, once in the workplace, find themselves changing bedpans, answering phones, or undertaking similar “low status” and low skill work. A second, more serious problem is captured through a feminist take on care work: As a society, we can all too easily perpetuate its low status through education paths. College and training credentials specific to care work ensure that it is always “someone else’s job.”

For me, this last question raises lots more ethical and economic questions about “good” work, “bad” work, and how it ought to be distributed in society. Someone has to clean the bedpans. Who should it be and why? Food for thought, and fodder for another blog. In the meantime, I have to go wash some sheet (a job for which I am grossly overqualified).

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1See my blog from last week about Physicians’ Assistants.

2The problem of being “rudely awakened” in practice is one shared by teachers. In our own Faculty of Education at the University of Alberta, present reform efforts in teacher preparation are in part spurred by a recognition that classroom learning and work-based learning (through practicums) needs to be better integrated. The culture shock of shifting from “ideal” to “real” is just intense.

3I want to emphasize that I’m not personally criticizing the nurse in question here. I’m more interested in whether her perceptions of her work are representative of some broader assumptions. The nurse’s comments do deserve to be heard in their context: The White Coat Black Art episode about burnout in the health professions was broadcast September 2, 2009, and is available for download. And WCBA is a terrific show by the way! Check it out.

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