Edited by Sioban Nelson and Suzanne Gordon
Ithaca, NY: Cornell University Press, 2006
224 pages; US$45.95 cloth, US$18.95 paper

Reviewed by Marie Edwards, RN, PhD
Assistant Professor, Faculty of Nursing,
University of Manitoba, Winnipeg, MB

Earlier this year, I learned about the results of a recent Gallup Poll in the United States. For the eighth year in a row, nurses received the highest ratings for honesty and ethical standards compared to other occupations (Saad 2006). This is good news. But after read- ing The Complexities of Care, a new book edited by Sioban Nelson and Suzanne Gordon, I have discovered that it might be important to ask the public at least one more question. The public may trust us, but do they think nurses are know- ledgeable healthcare providers? Nelson and Gordon identify that in one US poll, "those who thought nurses were ethical and honest apparently also believed they had only the most limited knowledge, and would not ask them questions about women's health, osteoporosis, or sexually transmitted diseases" (p.26). Why might that be? Answers to this question can be found in this book, and the issues it raises require our attention.

Nelson is dean of the Faculty of Nursing at the University of Toronto, and Gordon is a US journalist and author. Their book is a thought-provoking collection of 10 essays on nursing from the perspective of a sociologist, a journalist, a philosopher and seven nurses, working in Canada, the United States, Australia and the United Kingdom. In the book's introduction, the editors describe the genesis of their book and their interest in a particular paradox that has emerged today:

The public says it trusts nurses, yet it seems to tolerate a relentless series of assaults on the integrity of the profession. In our view, this paradox is neither accidental nor natural but, in great part, the logical consequence of the fact that nurses and their organizations place such a heavy emphasis on nursing's and nurses' virtues rather than on their knowledge and concrete contributions. Nursing today stresses the emotional and ethical aspects of its work and increasingly defines "caring" in a very particular way. (p.3)

The editors argue that the emphasis on caring in nursing has created problems for the nursing profession, and it is these problems that they explore.

The authors of this collection devote great attention to language, rhetoric and discourse. For example, Tom Keighley examines the rhetoric of health from the Declaration of Alma-Ata forward; Suzanne Gordon considers the rhetoric of holism; and Marie Heartfield explores the influences of "administrative discourses" (p.144) on the way we think about surgical recovery and hospital length of stay. Particular attention is paid to the caring discourse so evident in nursing today. To be clear, it is not that these authors are "anticaring" (p.11); rather, they believe, as Nelson and Gordon explain, that caring discourse has been "uncritically accepted as dogma rather than critically described or explored" (p.11). Nurses, it is argued, have a tendency to speak from a "virtue script" (p.19), one that reinforces "nursing's 'old image' as good work performed by kind and nice people (women), as opposed to skilled and intelligent work" (p.14). The opening essay examines the historical roots of this script, as well as the purposes it has served over time. It soon becomes apparent that this focus on caring conceals much of nursing work, including knowledge work, body work and basic nursing care.

Also described is the disconnect between the way nurses talk about nursing and what they are observed doing in their work. Two non-nurses contribute fascinating essays on this topic. Suzanne Gordon writes about her experiences working with, observing and listening to nurses over more than 15 years. She perceives that nurses have a tendency to downplay, even to devalue, the medical and technical aspects of their work while emphasizing the psychosocial aspects of their nursing care. Sociologist Dana Beth Weinberg, in an essay about her research on hospital restructuring in Boston, describes how nurses "floundered when confronted with the need to explain their work" (p.33), falling back on the language of relationships. Weinberg writes: "Nurses' focus on personal relationships prevented them from describing how care was being threatened when restructuring deprived them of enough time to know patients, and it bore little resemblance to the daily practice I observed" (p.34).

An important message in these essays is that what nurses say matters and what nurses focus on is important. In fact, the way nurses express themselves has consequences, and perhaps not the ones they intend. Weinberg describes this situation:

The lack of consistency between the nurses' abstract, relationship-oriented accounts and my daily observations of therapeutic activities that patients depend on was puzzling, particularly since the nurses at Beth Israel Deaconess Medical Center were a highly seasoned and professional bunch. More than puzzling, however, these responses became pivotal in the unfolding story of the dismantling of this famous nursing service. (p.31)

Other consequences of nursing's focus on a particular interpretation of care are presented throughout the book. In an essay on moral integrity and regret, philosopher Lydia Moland examines the way nurses interpret the concept of caring and how this interpretation may make it more difficult for them "to feel they act with integrity" (p.51). Using the example of palliative care nursing, Sanchia Aranda and Rosie Brown argue that the profession's focus on caring as "relational work" has led to the movement of skilled nurses into case management roles and the consequent delegation of basic nursing care to less skilled workers. This places patients in situations where they may receive "fragmented and inferior care" (p.123).

This is not simply a book about nursing's problems. Solutions to the problems are presented and discussed. Diane Mason, a journal editor, writes about nursing's "struggle with reasoned debate" (p.44) and encourages nurses to engage in open dialogue about the major issues facing their profession. Nelson and Gordon propose that nurses "rethink" (p.187) how they describe their work, and argue for a shift in focus from virtue to knowledge in nursing. In an informative essay on staffing research, Sean Clarke, a nurse researcher and academic, examines the challenges of studying "the substance of nursing - skilled and competent care provided within the nurse-patient relationship" (p.162) and offers suggestions regarding the directions that staffing research now needs to go.

The essays in this book are well written, accessible and interesting. The arguments put forward are well constructed, supported by literature and clearly articulated. One of the book's strengths is the inclusion of authors from a variety of locations (i.e., Australia, the United Kingdom, the United States and Canada), some of whose work was unfamiliar to me. I found myself almost immediately looking for other publications by these authors. The ideas presented made me think, and certainly challenged some of my preconceived notions about caring and nursing.

The book did leave me with some questions. In my experience working with and talking to critical care nurses over time, I have not found the "virtue script" to be predominant. In fact, I always walk away from these conversations marvelling at nurses' knowledge work. I wonder if it matters who asks the questions. Are the conversations nurses have with each other significantly different from the conversations they have with non-nurses (e.g., researchers from outside nursing, government officials, the public)? The answer may be that they are quite different. The book provides us with a sense of why that might be the case, but further exploration of this question would be useful. As someone who spends a fair bit of time thinking about ethics in nursing, I also wonder if we can have it both ways. Can we encourage a deeper, richer and more critical discussion of virtues in nursing, while still emphasizing our knowledge work?

The editors identify a single goal in putting together this collection: "to alert our colleagues and collaborators to the problems caused by the current discussion of caring and its impact on the way nursing practice is constructed" (p.185). The authors of the essays raise important questions for nurses to consider and debate. This is a book that should be read by direct care providers in nursing; nursing leaders in our workplaces, professional associations and unions; and academics.

It is also a book that will stimulate important discussion in nursing graduate classes. Nelson and Gordon warn readers in the opening pages that they should "be prepared to have their views challenged and their thinking stimulated" (p.12). From my perspective, they are successful on both counts, and their book is a welcome addition to the literature.

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