Cultural studies and historiography

A historian might argue that literary texts and other forms of cultural production, regardless of genre, tend to be fictions, or at least are imaginative presentations of reality, so are not reliable sources of historical data. Nonetheless, literary and other cultural representations tell us something about the people who crafted them, the people who read or observed them, and the cultures in which their production and consumption occurred. As Hayden White reminds us,“the discourse of the historian and that of the imaginative writer overlap, resemble, or correspond to each other.” ³ Historians, therefore, can profitably employ literary and cultural studies as part of a larger project of documenting and interpreting the history of the nursing profession and attitudes toward nurses.

Culture studies emerged in the mid-twentieth century from a variety of literary, philosophical, and political schools of thought (and conversely literary studies at the same time has been influenced by culture studies). Traditional literary studies, with its roots in Plato’s discourses on written language and poetry and Aristotle’s treatises on tragedy (Poetics) and public discourse (Rhetoric), had become by the mid-twentieth century focused primarily on formal, stylistic, and aesthetic dimensions of literary art. The approach of literary studies might be exemplified in a famous phrase of Victorian critic Matthew Arnold, for whom culture was “a pursuit of our total perfection by means of getting to know … the best which has been thought and said in the world,” ⁴ with Arnold providing his readers with the touchstones of “the best.” In contrast, culture studies in its origins saw its role as illuminating all that has been thought and said (not just “the best”), and not just in literary texts, defining “culture” much more broadly. Clifford Geertz’s influential The Interpretation of Cultures defines the term culture as “an historically transmitted pattern of meanings embodied in symbols, a system of inherited conceptions expressed in symbolic forms by means of which men [sic] communicate, perpetuate, and develop their knowledge about and attitudes toward life,” and Geertz explores the ways in which culture is a text to be interpreted. ⁵ In their introductory essay to the anthology Cultural Studies, Cary Nelson, Paula A. Treichler, and Lawrence Grossberg note the relationship between anthropology and cultural studies, but underscore the latter’s emergence from progressive political commitments. ⁶ Although Michel Foucault’s methodological weaknesses as a historian have been frequently noted, his The Birth of the Clinic: An Archeology of Medical Perception remains an important theoretical foundation for culture studies’ examination of healthcare discourses and practices. ⁷ Taking Foucault’s analysis as a starting point, Robert Hodge’s social semiotic Literature as Discourse:Textual Strategies in English and History illuminates the “social processes that flow through and irresistibly connect literary texts with many other kinds of texts, and social meanings that are produced in different ways from many social sites.” Adopting Foucault’s concept of discourse, Hodge sees “literature as a process rather than simply a set of products; a process which is intrinsically social, connected at every point with mechanisms and institutions that mediate and control the flow of knowledge and power in a community.” ⁸ Historicizing literary studies, Anthony Easthope’s Literary into Cultural Studies analyzes the dissolving of a distinction between literary “high culture”(such as fiction, poetry and drama) and popular “low culture”(such as film and television). ⁹

Culture studies’ object of study is everything and anything that has been thought, said, done, performed, manufactured, crafted, fashioned, communicated, and mediated. These “discourses” (a pliable term that includes phenomena beyond the printed page) can include traditional literary forms, but also personal correspondence, diaries, scrap-books, pamphlets, performances, and audio and video recordings, among other popular mass media. Some of these “artifacts” of culture are well known to historians as documentary evidence, so the question might arise: How differently does a scholar in culture studies interpret them? To start with, culture studies asks different questions from the historians’questions:What is the larger cultural system in which these artifacts are produced and how do they shape that system? How do these artifacts appropriate existing discourses or shape existing discourses? What cultural or ideological work do these artifacts perform? In what ways do these artifacts uphold cultural structures and in what ways do they subvert them? What claims do these artifacts make about reality and how do they argue those claims? How are these artifacts produced and circulated within a society? The literary text may be qualitative evidence for the historian, who asks if the text is credible or reliable as historical evidence or who uses the literary text to humanize the documentary record, but for culture studies the literary text (or a mass media form) is a component of larger systems about which culture studies theorizes.

By appropriating contemporary critical theory and by democratizing literary criticism and analysis, culture studies is concerned with political and material dimensions of culture, particularly the ways in which marginal cultures interact with dominant cultures. Culture studies is concerned with power, with the ways that cultural production creates social identity, and the ways that it legitimates, resists, or subverts existing structures of power, and leverages economic, social, or cultural capital. Culture studies strips away the cultural facades of political, social, and economic structures in order to reveal their disguised operations (which it assumes are always there regardless of a creator’s or society’s intentions). It is no wonder that culture studies approaches have often been adopted by scholars with commitments to underrepresented groups, such as women, sexual minorities, ethnic and racial minorities, and the disabled, which resonates with nursing historiography. As nurse historian Patricia D’Antonio has observed, nursing historiography is both an account of “the myriad ways in which women and some men reframed the most traditional of gendered expectations—that of caring for the sick” while it is also an account of the history of women. ¹⁰ The result is a complex subjectivity in the nurse and a paradox in the profession, what historian Susan Reverby has called the “dilemma of American nursing”in its first century, namely that being “ordered to care”nurses confronted “a series of limitations—of imagination, of cultural ideology, of economics, and ultimately of political power—in their efforts to care.” ¹¹ One other theme of the narrative of the nursing profession is “nurses’ desires to differentiate their work from other health-related pursuits, and for professional autonomy and visibility.” ¹² Buresh and Gordon refine that theme by noting that nurses’ invisibility is less the problem than nurses’ silence. To bridge this gap, culture studies provides the historian with useful insights into how societies have thought of nursing and how nurses have thought of themselves.

In the second half of the twentieth century culture studies began to examine the elaborate systems whereby certain groups were culturally as well as politically and economically marginalized.Self-representation, a term that has a decidedly political sound, becomes an important cultural resource for groups accustomed to being the objects of another’s literary or artistic representations, often by means of stereotyping. Solidarity or liberation movements among marginalized groups often undertake a campaign of cultural self-representation, both by cultivating artists and authors and by creating an infrastructure for making those self-representations public (e.g. establishing publishing venues such as periodicals or small presses). A culture studies approach to nursing history, then, is keenly interested not only in how others represent nursing (in novels, films, television, or advertising, for example), but also in how nurses represent themselves in cultural forms.

The twentieth century: conflict and competing narratives of ambiguity, agency, and autonomy

Literary representations of nursing in the twentieth century inherited from Victorian culture a range of archetypal images and stereotypes of nurses ranging from the benign to the malevolent. Nineteenth-century fiction and non-fiction depicted nurses as angels of mercy or as heroic healers (particularly in war narratives) or as the silent ancillaries of physicians or as young seductresses or as old battle axes. Nursing was represented as a noble profession but also as a romantic opportunity for adventure, particularly in novels whose lack of realism Florence Nightingale, herself a prolific writer, vigorously condemned. ¹³ Skilled and dedicated care of the sick was a major preoccupation of Victorian fiction in the hands of distinguished writers such as Charles Dickens, Jane Austen, Anne Brontë, Charlotte Brontë, Emily Brontë, George Eliot, and Elizabeth Gaskell. ¹⁴ These nursing characters and narratives were widely read, often published initially in mass-circulation periodicals that also featured the debates of the day, including articles and editorials concerning nursing, ¹⁵ which in turn were discourses that shaped literary texts, representing the period’s concerns with “relationships between men and women, upper and lower classes, employers and employees, professionals and laypeople.” ¹⁶ These social fault lines would deepen after the Victorian era in a period of accelerated change.

The twentieth century witnessed catastrophic war technologies and convulsive social movements, both on unprecedented scales, and both affecting nursing. ¹⁷ Nurses saw their professional roles expand, but not without controversy, and their increased visibility occasioned sometimes ambivalent responses. As a largely female health profession, nursing was affected by the woman suffrage movement in Europe and North America in the early twentieth century. A dominantly (though far from exclusively) White profession, US nursing also had to come to terms with the growing social and political movements for Black equality.

Nurses during World War I wrote about their experiences from a variety of motives and often may have believed that their role was to uphold morale, particularly in their letters home. For example, Pauline McVey asserted for an American readership:

The spirit of the boys was wonderful. They had a few desires which constantly obsessed them. The predominant one was to be mended as soon as possible so that they could get back to their units. They were of the opinion that to lose connections with their outfits was even more to be regretted than the missing of a limb, or a severe operation of some other nature. ¹⁸

However, not all nursing representations of World War I military hospitals were as uncritical of the war’s conduct. Two writers, Ellen Newbold La Motte (a professional nurse, administrator, and specialist in tuberculosis care) and Mary Borden (a wealthy philanthropist and volunteer nurse whose initial frustration with the war’s wasted medical resources prompted her to fund and establish her own frontline medical unit, which La Motte joined), wrote narratives representing the full moral ambiguity of the war. Both La Motte and Borden drained their narratives of the sentimentality or even sensationalism that had tended to characterize earlier nurse war texts from the Crimean War and the American Civil War, and both employed the concise genre of the sketch. La Motte’s The Backwash of War, published during the war,“was so frank and powerful that it could not be distributed in England or France. By 1918, with American troops finally going over to France, the U.S. government inked out advertisements for the book in the Liberator, a monthly on whose editorial board La Motte was serving.” ¹⁹ In The Forbidden Zone, published after the war, Borden asserts:“I have not invented anything in this book. The sketches and poems were written between 1914 and 1918, during four years of hospital work with the French Army. The five stories I have written recently from memory; they recount true episodes that I cannot forget.” ²⁰ In eerily paired accounts of the same patient, La Motte in “Heroes” and Borden in “Rosa” relate the case of a soldier who has attempted suicide in order to escape the horrors of war but who must be saved in order to try him for desertion, a capital crime for which he will be found guilty and executed. As the editor of a recently published anthology of Borden and La Motte’s wartime writings, Margaret Higonnet, notes:“Military hospitals preoccupied with detecting fake wounds suppressed suicide reports,” ²¹ and, as Joanna Bourke documents, self-inflected wounds could account for as many as one-quarter of a division’s casualties not directly attributable to enemy fire. ²² Both of these nurse writers represented the horror, irrationality, and mendacity of the war with the same indignation as many of the war’s greatest poets, such as the British-born Wilfred Owen and Siegfried Sassoon.

While wartime nurses were acutely aware of combat’s horrors, they might also have been excited by the opportunities that nursing provided: a wider scope of action, an opportunity to contribute to a larger national cause, learning needed technical skills, and having occasions for leadership. In contrast to depictions of the horrors that wartime nurses witnessed, at mid-century young female readers were introduced to popular literary representations of nursing as an exciting, varied, and personally fulfilling career. Popular career narratives featuring the characters Sue Barton (in books written by Helen Dore Boylston after World War I) and Cherry Ames (in a book series initially authored by Helen Wells during World War II, with subsequent books written by Julie Tatham, before Wells returned to writing the series), these fictions reflect changing gender expectations, representing young women as energetic, autonomous, adventurous, and career-minded. Boylston, a World War I nurse, also wrote Sister:The War Diary of a Nurse ²³ and Clara Barton: Founder of the American Red Cross. ²⁴ Although Boylston’s character Sue Barton had a steady romantic interest (Bill Barry, MD), their marriage was continually deferred from one book to the next while Sue climbed the nursing career ladder, from student nurse to hospital superintendent of nurses. Along the way she practiced nursing in a variety of settings: home visiting, rural, urban, hospital, and public health nursing. By the time Barton finally married Dr Barry (who had become a hospital director), her husband developed pneumonia and was bed-ridden, leaving Barton to run the hospital in his absence. As Deborah Philips observes, “Nursing is consistently constructed in the Sue Barton novels as an appropriate means for a young woman to achieve some measure of financial independence and professional status and to contribute to the social good.” ²⁵ Viewing themselves as candidates for meaningful careers outside the home, young female readers might see nursing as rewarding and varied work that did not necessarily preclude marriage.

If Barton was a focused and ambitious career professional, advancing in rank from one position to the next, her plucky counterpart Cherry Ames had more in common with the better known adventurous youth-literature characters, the Hardy Boys and Nancy Drew. In a series of 27 books published between the early 1940s and the late 1960s, Ames was alternatively depicted as contributing to the war effort during World War II (and encouraging the books’ readers to do the same, in the books written by Helen Wells), as an adventurous amateur sleuth in the immediate post-war years (in the sequels written by Julie Tatham), and as a glamorous lifestyle figure in the final novels (which marked the return of Helen Wells’s authorship). As Anita G. Gorman and Leslie Robertson Mateer observe: “Changes in authorship, Cherry’s character, Cherry’s vocation and relationships all reflect the shifting paradigms of a series adapting to changing conditions in both the world around it and the world it so assiduously portrays.” ²⁶ As much representations of historically contingent social norms changing over time as they are of the changing realities of nursing, the books and their different authors were responding to young readers’ interests (or at least the publisher’s understanding of them). Unlike Sue Barton, Ames had no steady love interest, although each novel has a romantic subplot, and her multiple and varied jobs (Country Doctor’s Nurse,Dude Ranch Nurse,Jungle Nurse,Department Store Nurse) do not seem to constitute a career trajectory but are opportunities for adventure. Across two and a half decades and two authors, the Cherry Ames series “broke ground by depicting a woman with a career, a woman who did not see marriage as her immediate or ultimate goal, a woman who showed some independence and insubordination as well as the more conventional qualities of beauty, compassion, and adherence to hierarchical organization.” ²⁷ Betting on these novels’ enduring popularity, in 2005 the health science publisher Springer reissued the books in boxed sets, aiming for a seemingly discrepant demographic by announcing on one hand,“Cherry Ames is back, just as you remember her! The books are just as you remember them,” while on the other hand claiming Cherry’s timeless youthfulness and appeal for today’s younger readers:“making friends, pushing the limits of authority, leading her nursing colleagues, and sleuthing and solving mysteries. Smart, courageous, mischievous, quick-witted, and above all, devoted to nursing, Cherry Ames meets adventure head-on whereever [sic] she goes. Springer Publishing Company is delighted to be bringing Helen Wells’s beloved heroine back into print for a new generation of younger readers.” ²⁸ Perhaps as well the publisher is counting on the series’ innocent and uncomplicated depictions of nursing as a welcome tonic to readers after the darker, more conflicted nurse characters of the past fifty years.

The rewards of submitting oneself to an ordered profession, joining a community engaged in noble work, and even having opportunities for global travel occurred not only in wartime or civilian settings, but also in Catholic religious life. In Kathryn Hulme’s The Nun’s Story ²⁹ (later adapted into Fred Zinneman’s 1959 film of the same name and Zoe Fairbairns’s radio play The Belgian Nurse), events in the life of Mary-Louise Habets (1905–1986) were novelized and dramatized. Habets, a nurse, entered the Roman Catholic religious order Soeurs de la Charité de Jesus et de Marie in Ghent, Belgium, in the late 1920s, and was trained for tropical nursing in the Belgian Congo where she served through much of the 1930s, returning to Belgium shortly before its invasion by the Germans and the onset of World War II. Chafing under the strict rule of the order and growing more conflicted at the order’s neutrality during the Nazi occupation, she left the convent in 1944. Hulme and Habets met in Europe after the war, thereafter becoming lifelong companions, as well as literary collaborators in The Nun’s Story, with Habets’s work as a nurse subsidizing the household while Hulme pursued a literary career. When Zinneman proposed turning the book into a film, Hollywood studio executives were not receptive until Belgian-born actress Audrey Hepburn expressed her interest in the role (into which she was cast). In one of the extraordinary instances of life imitating art, Habets later helped nurse the actress who played her dramatized self, Hepburn, after the actress experienced a riding accident. Debra Campbell in a conference paper on the book and film observes:

Catholic readers/moviegoers and Catholic historians alike have trouble knowing what to do with The Nun’s Story. Like most contemporary reviewers of the book and film, we do not quite know how to read and evaluate a narrative that feels like fiction but claims to be “true in its essentials.” Do we dare to treat The Nun’s Story like an authentic life-writing, even perhaps a personal narrative? ³⁰

Historians might ask that question concerned primarily with the text’s reliability as a historical document. However, from the perspective of culture studies, as Campbell concludes,“we need more life studies of twentieth-century Catholics and how the study of personal narrative takes historians of Catholicism to places that we could reach in no other way.” So might historians of nursing, appropriating culture studies, concur about The Nun’s Story. In other words, for culture studies, the novel’s very ambiguity is an occasion for an open-ended discussion about representation or self-representation and its relationship to historical context. What readers of the book come to see, for example, is the extent to which the culture of Catholic religious orders prior to the reforms of the Second Vatican Council in the 1960s had a martial quality, with an extended and rigorous basic training, a uniform code of conduct, and strict adherence to hierarchy and regulations. This same rigor would not have been unfamiliar to nurses who trained in the 1940s and 50s, so that the profession of nursing and profession of religious vows appear to coexist as twins of each other in certain respects, which reminds us of Nightingale’s admiration for Catholic women religious in healthcare vocations. ³¹

A kind of martial discipline—creating and sustaining order on behalf of patients’ wellbeing in the midst of chaos and attending to details, even being a stickler for policies and procedures—may have been characteristics of a competent nurse through the middle of the twentieth century. ³² However, in the ethos of the 1960s at a time when all institutions and conventions came under scrutiny, not least the healthcare establishment, Ken Kesey’s representation of Nurse Ratched (or “Big Nurse”) in the novel One Flew Over the Cuckoo’s Nest ³³ (later made into the 1975 film of the same title) sounded a responsive chord with its caricature of a castrating female and clinical dictator. Mental health professions had often been the subject of dramatic or melodramatic representations:Spellbound, Hitchcock’s 1945 tribute to Freudian analysis;The Snake Pit, Anatole Litvak’s 1948 castigation of mental asylums; The Three Faces of Eve, Nunnally Johnson’s 1957 quasi-documentary dramatization of multiple personality disorder; and Suddenly, Last Summer, Joseph L. Mankiewicz’s 1959 film version of Tennessee Williams’s play in which a psychiatrist finds himself pressured by a wealthy benefactor to lobotomize her daughter, quickly come to mind. In each instance, the mental health professionals believe themselves to be well-intentioned but are, in fact, emotionally conflicted and ethically confused. In Kesey’s counter-cultural ethos, Nurse Ratched personifies all that is wrong with contemporary America (conformity, intolerance of difference, adherence to unjust laws), but what makes her malevolent (rather than merely a comic foil) is her absorption and manipulation of power, against the patients, her staff, and the physicians. In Leslie Fiedler’s analysis:

In part Kesey’s attitude can be explained by the age which bred him and whose spokesman he became: a revolutionary time, when all hierarchal institutions, not least the hospital, had come to be despised, and all professions, specialties— especially, perhaps, medical ones, and most especially psychiatry—were regarded with hostility and suspicion. After all, in the late sixties, as reading R. D. Laing reminds us, madness had come to be venerated in many quarters as a higher kind of sanity. ³⁴

For the post-Freudian Kesey, who had worked in a psychiatric hospital during his graduate studies and had volunteered in a CIA-funded study of LSD at a veterans hospital, Nurse Ratched is all Superego and castrating female. However, she is not alone among nurses in the novel, all of whom (including the “little” Japanese nurse and the Catholic nurse) seem the object of Kesey’s contempt. As Leslie Horst notes:

The women [including the wives of the male patients] … seem lost all along, hopelessly imprisoned in the narrowest of sex-roles or in projections of male fantasy … Not only is the portrayal of women demeaning, but considerable hatred of women is justified in the logic of the novel. The plot demands that the dreadful women who break rules men have made for them become the targets of the reader’s wrath. ³⁵

Anxieties among nurses about their role and scope of practice in the 1960s appear to have collided, at least in the United States, with broader social anxieties about the role and scope of women’s work in society and about the unquestioned authority of healthcare professionals. These anxieties would become amplified in the 1970s over the emerging gay rights movement and feminist movement, and in the 1980s at the beginning of the HIV/AIDS epidemic, when health research and healthcare became, to an unprecedented degree, contested and politicized.

In the early 1980s HIV/AIDS did not initially affect a broadly defined “general population”since its two most common vectors of transmission are IV drug use (sharing infected needles) and unprotected or “unsafe” sexual practices, usually with multiple partners and often in anal sex between men. The stigma associated with these behaviors and a recently visible and vocal Christian conservative political activism combined to circulate a rhetoric of apocalyptic vehemence in which a public health issue became inflected as a biblical plague, God’s judgment on sinners. ³⁶ Because the initial cases of AIDS were documented by epidemiologists and represented in the media as a problem of two marginalized groups (gay men, Afro-Caribbean Haitians), individual nurses caring for AIDS patients would have been challenged in their own attitudes about minorities and proscribed behavior. ³⁷ In the first decade and a half of the epidemic, social dissent, political dissent, and epidemiological dissent emerged, influencing both the research agenda and the provision of healthcare. ³⁸

One of the more important cultural representations of the epidemic, Tony Kushner’s two-part epic drama Angels in America, ³⁹ depicting the AIDS epidemic in the 1980s during the Reagan Administration, is conspicuous in its featuring a nurse as a central character, Norman Arriaga (also known by his drag name as “Belize”), an Afro-Puerto Rican gay man who is the faithful friend to (and former lover of) the play’s protagonist, Prior Walter, and who is the play’s moral center of gravity. In doing so, Kushner subverted what had become a common AIDS narrative in which a physician (either angelic or demonic or some mixture of the two) was the representative healthcare professional, nurses generally being either absent or spectral (visible, but wielding little professional power or influence on the narrative). Campy, witty, and sharp-tongued, Belize provides his patients with both competence and care. Visiting Prior in the hospital, Belize massages him: Prior:

This is not Western medicine, these bottles …

Belize:

Voodoo cream. From the botanica ’round the block.

Prior:

And you a registered nurse.

Belize (Sniffing it):

Beeswax and cheap perfume. Cut with Jergen’s Lotion. Full of good vibes and love from some little black Cubana witch in Miami. ⁴⁰

Later, preparing to leave Prior’s hospital room: Belize:

I have to go. If I want to spend my whole lonely life looking after white people I can get underpaid to do it.

Prior:

You’re just a Christian martyr.

Belize:

Whatever happens, baby, I will be here for you.

Prior:

Je t’aime.

Belize:

Je t’aime. Don’t go crazy on me, girlfriend, I already got enough crazy queens for one lifetime. For two. I can’t be bothering with dementia. ⁴¹

The historical figure of Roy Cohn (right-wing Republican power broker and closeted homosexual who rose to fame as an assistant to Senator Joe McCarthy in the 1950s) appears throughout the play, a character of almost Shakespearian evil. Diagnosed with AIDS (which he denies because only “fags” get AIDS), Cohn is eventually hospitalized and becomes Belize’s patient: Belize:

This didn’t come from me and I don’t like you but let me tell you a thing or two:They have you down for radiation tomorrow for the sarcoma lesions, and you don’t want to let them do that, because radiation will kill the T-cells and you don’t have any you can afford to lose. So tell the doctor no thanks for the radiation. He won’t want to listen. Persuade him. Or he will kill you.

ROY:

You’re just a fucking nurse. Why should I listen to you over my very qualified, very expensive WASP doctor?

Belize:

He’s not queer. I am. ⁴²

Here Belize gestures to two phenomena: first, a utopian assertion that the difference of queer identity may transcend differences of class, race, and ideology; second, that healthcare professionals at the time (with some improvement in the intervening three decades) were conflicted at best about their patients’ non-normative sexual behaviors and could not always be trusted to provide care in the patients’ interest. As though to emphasize the latter point, Belize also advises Cohn to pull strings in order to secure medications from federal AZT trials but advises him not to sign up for the trial itself, where he might only receive a placebo:“You’ll die, but they’ll get the kind of statistics they can publish in the New England Journal of Medicine.” ⁴³ This generosity on Belize’s part is rewarded later in the play after Cohn dies, when Belize takes possession of Cohn’s stash of AZT in order to provide it to Prior: “He was a terrible person. He died a hard death. So maybe … A queen can forgive her vanquished foe. It isn’t easy, it doesn’t count if it’s easy, it’s the hardest thing. Forgiveness. Which is maybe where love and justice finally meet.” ⁴⁴ This last statement, consistently enacted throughout the play by Belize’s refusal to abandon either his friend Prior or the despicable Roy Cohn, by his subordinating his own personal feelings and political commitments on behalf of the wellbeing of the patient Cohn, and by his willingness to tell the truth (to Cohn and to Prior’s boyfriend Louis, who has left Prior after learning of his AIDS diagnosis), summarizes the play’s central theme in which Belize has served as the moral exemplar: the meeting of love and justice.

Angels in America’s representation of one nurse evokes the questions of personal visibility and professional autonomy that have been dominant themes in the nursing literature throughout the twentieth century. As a gay man, as an Afro-Caribbean, as a nurse, and as a man in nursing, Belize is multiply constrained in regard to visibility and autonomy. In addition, Kushner depicts a profession that is still considered culturally and professionally contingent on and ancillary to medicine and that is self-consciously concerned with questions of social justice and ethical ambiguity. At the same time, the character of Belize also raises issues about a marginalized minority within a frequently professionally marginalized healthcare field: men. Stereotypes of men in nursing (only gay men go into nursing; men in nursing are a new phenomenon) belie the complex (and sometimes invisible) history of gender in the nursing profession. ⁴⁵ Although it is unclear why Kushner chose to write Belize as a nurse, he has expressed his own ambivalence about the character and the politics of representation:“I was wrestling, and I’m still wrestling, with the whole question of representation and the rights of representing different people’s experience. The issue of a white writer writing a black character is so loaded. And I made mistakes when I started the play in 1988 and if I were doing it over again I probably wouldn’t make him a nurse; having read Toni Morrison’s Playing in the Dark I would have avoided that.” ⁴⁶ Kushner refers to Morrison’s “Disturbing Nurses and the Kindness of Sharks,” one of her William E. Massey Sr Lectures in the History of American Civilization at Harvard, ⁴⁷ in which Morrison limns the paradox of the ubiquity and invisibility of race in American culture and associates it with gender. In an analysis of Hemingway’s fiction, Morrison sees a preoccupation with nurturing people of color (men and women) who attend to the white male protagonists. Thus Kushner’s multiple anxiety about his representing Otherness (the Afro-Caribbean male nurse), inflected through a cultural stereotype of servitude with its long pedigree, supports a culture studies refusal of facile or naïve notions of representational realism. Culture studies helps the historian to ask the right questions about any text without begging the question of a text’s representational authority.

As seen on TV

Although fiction, drama, and film have been important forms of cultural production for nursing, in the second half of the twentieth century television probably exerted more widespread cultural influence than any other medium in the Western world on how people imagined themselves and saw others. Seeking cultural validity in the 1950s, television producers aspired to present serious drama and documentary reporting, but by the 1960s television’s commercial success had led to the establishment of commercially safe genres, such as half-hour situation comedies, daytime serialized dramas (soap operas), and hour-long evening dramatic or adventure programs. Their ensemble casting did not require new exposition each week, and the characters rarely developed over the course of a season. The success of one network’s programming spawned imitations by the others (like the proliferation of Westerns in the 1950s).

In the 1980s meticulous analysis of nursing representations in popular media came from the groundbreaking interdisciplinary research of Philip Kalisch, a professor of history, politics, and economics in the Center for Nursing Research at the University of Michigan, and Beatrice Kalisch, a professor of nursing at the University of Michigan, using social science methods of content analysis. In one longitudinal study of television from 1950 to 1980, the researchers characterized the predominant representations of nursing: the nurse appears as a resource to other healthcare providers and an emotional support for families and patients, but rarely as a professional providing education or demonstrating a scholarly or expanded role. This longitudinal study also noted that an emphasis on nursing’s contribution to patient welfare and television’s emphasis on professional nursing peaked in the 1960s, and declined precipitously in the 1970s. ⁴⁸ The researchers identified a similar pattern in popular fiction, though novels seem to have been a leading indicator with researchers noting that fictional representations of nursing reached a pinnacle in the 1940s and early 1950s, followed by a precipitous decline in the later 1950s and 1960s when nurses tended to be relegated to two familiar stereotypes: the frigid unmarried authoritarian nurse and the sexually available young nurse (both female). ⁴⁹ More recently a Kalisch study of representations of nursing on Internet websites in 2001 and 2004 suggested a more mixed picture, including declines in representations of the characteristics of nurses as authoritative, scientific, creative, and powerful. ⁵⁰ While such quantitative analyses might be familiar to the historian, they do not constitute a culture studies approach, but they can be the occasion for the culture studies scholar to theorize more broadly about the cultural systems in which they were produced and the ways in which other discourses of gender and professions were imbricated in the same period.

Hospital and medical dramas featuring nurses have been a perennial television genre, though their representations of the nursing profession have often been subordinated to the requirements of melodramatic or humorous plots. And television may be a representation of the culture’s Id at certain historical moments, telling us more about the times than about nursing. For example, ABC’s General Hospital, launched in 1963, is now the longest-running daytime drama on American television. Although professionally ancillary to physicians, nurses in the show have been represented in a variety of dimensions and relationships, both professional and personal. In another instance, although professionally competent and a stickler for the rules, the character of Major Margaret “Hot Lips”Houlihan, RN, in M*A*S*H (which aired for over a decade and was based on the 1970 feature film adapted from Richard Hooker’s 1968 novel MASH:A Novel about Three Army Doctors), underwent a transformation from harridan to sharing “in the audience sympathy for the irreverent, iconoclastic, yet utterly humane doctors who work in a field hospital,”while nursing itself was presented “more forcefully and positively in [the show’s] last two seasons.” ⁵¹

The proliferation of cable television changed the media landscape, drawing some contrasts between older broadcast shows and new cable network programming. Perhaps the contrast between Nurse (a critically acclaimed but short-lived CBS drama of the early 1980s) and Nurse Jackie (a production of cable television’s Showtime starting in 2009) tells us more about changes in social norms and what was permissible in media production at the times each was made. The star of Nurse, actress Michael Learned (famous as the beloved and wise mother in The Waltons), won an Emmy Award for her performance as Mary Benjamin, RN, in Nurse; the show’s premise was that Benjamin had returned to her nursing career after the death of her husband, a physician, and she became a supervising nurse. The program suggested to viewers that nursing might be a career that is interrupted and returned to later (although it also leveraged some of the stereotypes of nurse–physician romance). As a network program aired in prime time, Nurse was required to observe broadcast standards of the day. In contrast, Nurse Jackie (which features Edie Falco in the title role) offers a darkly complicated and unsentimental view of the nurse. A highly skilled health professional, Jackie Peyton is also drug addicted, with a densely cluttered psychological landscape. Because subscriber-based cable programs are not constrained by the Federal Communications Commission’s decency regulations as CBS had been, cable programming such as Showtime’s can present edgier dramas than those of broadcast networks such as CBS. However sensationalist the plot summary of Nurse Jackie may appear, the show’s depictions of nursing have prompted the organization The Truth About Nursing, in its website’s reviews of television programs and films, to characterize it as “the most thoughtful and persuasive treatment of nursing issues on U.S. television.” ⁵² The New York State Nurses Association, however, has been less happy with the character, requesting the display of a disclaimer before each episode, ⁵³ a request that was denied. The American Nurses Association likewise issued a call to action to its members, providing a sample letter of protest. ⁵⁴ Thus the nursing profession finds it difficult to shape others’ representations of it, in part because the profession does not always speak with one voice and has limited resources for corporate self-representation.

Where are nurse writers?

The problem of cultural self-representation is a consistent theme of nursing’s history. The title of Nightingale’s classic book formulated the problem clearly (without permanently resolving it): Nursing, What It Is and What It Is Not. Nurses still need to explain that. And even today, if you were to ask a well-read friend to name a physician writer, your friend probably could name several (Jerome Groopman, Oliver Sacks, Atul Gawande come quickly to mind) who appear regularly in popular print publications. If you ask your friend to name a nurse author, however, you might be met with abashed silence. Where are the nurse writers in popular forums?

Several explanations for this relative invisibility come to mind. First, nursing has disproportionately employed women, and women’s sometimes precarious position in the cultural politics of writing and publishing may account for the seeming absence. However, the claims of gender disparity should not be hardened into a stereotype, since in significant instances over the past two centuries women writers’ enormous popular success has been the lament of male writers (such as Nathaniel Hawthorne’s famous complaint about the “damn’d mob of scribbling women” who edged him out of the literary marketplace). The cultural visibility and commercial success of women writers in the second half of the twentieth century and in the early twenty-first also complicate this explanation. However, Virginia Woolf’s famous observation that writing requires a room of one’s own (both in the literal sense of a space reserved for writing and in the metaphorical sense of enjoying the leisure of time to write) ⁵⁵ may be apposite. In addition, women in nursing often leave their physically, mentally, and emotionally demanding roles as health caregivers to go home, where they are engaged in the physically, mentally, and emotionally demanding roles in caregiving to spouses and children or aging parents. For them there is little time or energy for writing. Another explanation may derive from the discrete historical roles of physician and nurse (which are not without their historically gendered dimensions): the physician who ponders, diagnoses and prescribes (then leaves the bedside) in contrast to the nurse who provides a variety of forms of care, carries out the physician’s “orders,” and keeps continuous vigil with the patient at the bedside. The physician’s role historically has also included reporting on interesting cases, published in professional or scholarly journals. Literary writing by physicians (the essays and narratives published in popular magazines and books, which often entail case studies written for a general audience) may be an extension of that tradition of professional writing.

Educational attainment might also provide an explanation for cultural under-representation. All physicians have completed a baccalaureate curriculum, graduate training in medical school, and a residency; the majority of nurses have not. While educational attainment does not preclude a writing career, advanced education is probably conducive to it, at least by providing role exemplars and professional mentors. Also, an ethos of nurses’self-effacement (combined with a cultural script that celebrates the heroic physician) may render less successful the work of those nurses who do publish. Finally, Buresh and Gordon suggest an even more tenaciously ingrained reticence among nurses, who “often seem as hesitant to tell their friends and relatives about their work as they are to tell the New York Times or the Globe and Mail.” ⁵⁶ Alone or in combination, these conditions may have created an ethos in which nurses either do not write about their experiences or are discouraged from doing so, thus limiting cultural self-representation.

The irony is that the nineteenth-century founder of modern professional nursing was herself a prolific writer on a variety of topics in a variety of forms. Who are Florence Nightingale’s literary heirs today? Among them are men and women. They are working in a variety of genres, and their work has achieved canonical status in anthologies. Cortney Davis and Judy Schaefer’s two collections, Between the Heartbeats: Poetry and Prose by Nurses ⁵⁷ and Intensive Care:More Poetry and Prose by Nurses, ⁵⁸ have brought nurse writers to a wider audience. Schaefer’s more recent anthology, The Poetry of Nursing: Poems and Commentaries of Leading Nurse-Poets, ⁵⁹ gives 15 nurse poets the space to present and to comment on three or four of their own poems, an unusual and engaging meta-analysis. An accomplished poet, Davis is also a talented essayist, whose recently published The Heart’s Truth: Essays on the Art of Nursing encapsulates the relationship between clinical practice and writing, not as conflicting but as mutually supportive:

I find that when I’m not seeing patients, it’s a struggle for me to write. It seems that for me, nursing and writing have become, over the years, inextricably bound. That intimate connection that links us, human to human, is essential both to my vocation and my avocation. ⁶⁰

Nurse writers such as Davis and Schaefer, Jeanne Bryner, Theodore Deppe, and Veneta Masson have published their work in distinguished literary journals, such as Minnesota Review, Prairie Schooner, Hudson Review, Poetry, The Sun, and Kenyon Review, as well as in their own books published by respected presses. One more recent welcome development is that Theresa Brown, RN, a former professor of English and author of Critical Care:A New Nurse Faces Death, Life, and Everything in Between, ⁶¹ has moved from regular blogger for the New York Times to one of its regular columnists, for “Bedside,” the paper’s new op-ed feature that promises to represent nurses.

The uneven quality of representations of nursing in literature and mass media suggests the ways in which the nursing profession is wise to advocate on behalf of fairness and accuracy. Moreover, the unevenness is consistent with a cultural history in which these depictions have often been out of the control of nurses themselves. Culture studies can offer an account of nurses’ efforts at cultural self-representation and advocacy and can suggest why some have succeeded while others have not.

Future directions for scholars of nursing and its history should include the further recovery of nursing’s texts and cultural artifacts, both published and unpublished. Although the situation may have improved in the past twenty years, Susan Reverby’s observation in 1987 is still probably valid to a great extent:“Much of nursing’s history still lies buried in attics, slowly disintegrating in forgotten hospital file cabinets, or fading in the memories of older nurses.” ⁶² Using diverse sources, cultural studies scholarship over the past decade or more has produced some exemplary work, such as literary scholar Jane Schultz’s documentation and analysis of American Civil War female nurse narratives, Margarete Sandelowski’s study of the material culture of nursing and its visual representations in the use of technology, and comparative literature scholar Margaret Higonnet’s groundbreaking work with twentieth-century Modernist-era nurse authors. Schultz, a professor of English, meticulously historicizes published and unpublished diaries and memoirs of women who served in Civil War military hospitals, documenting their production and reception. ⁶³ Sandelowski, a nurse and American studies scholar, employs archival sources (including ephemera), professional publications, biographical and autobiographical literature, and interviews to read between the lines, filling in gaps and silences in the discourse. ⁶⁴ Higgonet’s work is remarkable both for her editing works long out of print and for her perceptive literary analysis in which she has moved these figures from the background to the foreground of literary history. In addition to making available for readers today the World War I writings of Ellen La Motte and Mary Borden, ⁶⁵ Higonnet has argued persuasively for the ways that those writers influenced and were influenced by more famous Modernist figures. ⁶⁶ Building on their work and learning from their methods, nurse historian Jennifer Casavant Telford and I in an article in the British Medical Journal’s Medical Humanities apply sociologist Daphne Spain’s critical analysis of gendered spaces to the physical space of the Union Civil War hospital and the literary “spaces” of the pages of subscription-published nurse narratives. ⁶⁷ Since academic nursing, unlike most fields in the humanities, has a robust tradition of co-authorship in joint studies, nursing historians and cultural studies scholars might profitably collaborate in this research.

Furthermore, nursing leaders, educators, scholars, and professionals should consider why nursing seems under-represented in the literary marketplace (or the larger cultural forum), at least when compared to its medical colleagues, many of whom are well established in the literary canon. They might start by supporting mentors for nurses’ writing and publishing and providing incentives for nurses to encourage their writing. Remedying that imbalance would be a worthy project because the stories and insights of nursing practice are indispensable to advancing human health and to our understanding of wellness and illness, of health and disease, and of the gendered dimensions of work. Scholars in cultural studies, along with historians, can also elucidate for nursing leaders nationally and globally the cultural and historical mechanisms whereby nurses’ and the public’s perceptions of nursing have been shaped, and can suggest strategies for the profession’s more accurate and visible self-representation.