The demands of the pandemic have left nurses feeling burned out, undervalued, and unsupported, and unprecedented numbers say they’re planning to leave the job. But while COVID-19 has exacerbated challenges in nursing, historians and health experts say the roots of discontent can be traced back through the history of the profession and to how society values — or doesn’t value — so-called women’s work.
In the late 19th century, hospitals were seen as little more than poorhouses; untrained staff were given a daily beer allowance. If they were to offer effective medical treatment and transform their reputation, they’d need a trained workforce, and it would have to be respectable — from the middle and upper classes — in order to attract those patients who typically paid for private home care, explains Kathryn McPherson, a history professor at York University. Hospitals began recruiting women to care for the sick “because men were historically more expensive than women,” and many young women were looking for better work options, says McPherson, author of Bedside Matters: The Transformation of Canadian Nursing, 1900-1990.
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Ontario’s first nursing school opened in 1874 at the General and Marine Hospital, in St. Catharines. The Toronto General Hospital followed, establishing its own nursing school in 1881. The student nurses lived in the hospital and slept on straw beds. In addition to caring for the sick, they served the meals and washed the dishes. From the beginning, hospitals used nursing-school entrance requirements to present nursing as a respectable occupation, says McPherson. Prior to the Second World War, requirements included being an unmarried or widowed female between 18 and 35 with at least a Grade 9 education (that was soon raised to Grade 11 or 12) and fluency in English or French, which ruled out many immigrants. It wasn’t until 1947, after advocacy from Black activist women, that the first Black student, Marisse Scott, was admitted to a nursing school, at Guelph’s St. Joseph’s Hospital.
As hospitals grew in the early 20th century, they continued to establish nursing schools. But despite increased government investment in health care, hospitals were underfunded and relied heavily on free student-nursing labour. A 1946 editorial in Toronto Star referred to nurse training as “in effect a labour ‘indenture’ system, under which young girls who want to become nurses are required to ‘work their way’ to a diploma.”
Nursing students worked 12-hour days on top of their studies and had limited time off; they were required to live in the hospital’s nursing residence, which enforced strict rules and curfews. Frances Harold, 95, who graduated from St. Joseph’s School of Nursing in Hamilton in 1946, remembers being punished for not stopping on the stairway to let a senior nurse to pass by. “A few of us got locked up for a few hours or more for talking and little things like that,” says Harold, who was briefly barred from leaving the residence due to the stairway infraction. Students were expected to line up in the mornings for inspections of their hair and uniform before they left for work on the wards.
The harsh learning environments occasionally led to conflict. In 1948, nursing students at Victoria Hospital, in London, rebelled when their two half-days off were cancelled because of too much noise in the nurses’ residence, according to a report in the Globe and Mail. When the students refused to go to work, the administration backed down.
In the 1960s, hospitals faced a shortage of nurses as more occupations became open to women. Politicians blamed the strict residence rules for discouraging young women from enrolling in nursing schools. In a 1962 Globe and Mail article, New Democratic Party leader Donald MacDonald is quoted as comparing nursing residences to “reform institutions”; he urged the government to take nursing education out of hospitals and make it available to students “the same as any course in a university.”
This apprenticeship system was dismantled in the early 1970s, when the Ontario government put colleges and universities in charge of nurse training. But despite the gains in education and training — since 2005, for example, registered nurses in Ontario have required a university degree — vestiges of the old system remain in place, says Kathleen MacMillan, past director of and professor at Dalhousie University’s School of Nursing and former chief nursing officer for the Ontario Ministry of Health and Long-Term Care: “There’s been a systematic devaluing of women’s work, and there’s still a lack of understanding of the knowledge base you actually need to be a nurse. It doesn’t come on your X chromosome.” And nursing, she adds, is still seen as women’s work (more than 90 per cent of Ontario’s registered nurses identify as female). She says she has been challenged by physicians who don’t understand why nurses need so much classroom learning: one doctor, she says, asked, “Why can’t we just put them in uniforms and put them on the unit like they used to?”
The continued undervaluing of so-called women’s work is reflected in the province’s controversial Bill 124, says Deb Lefebvre, a registered nurse and board member at the Registered Nurses’ Association of Ontario. The legislation, which came into effect in 2019, placed caps on public-sector compensation but exempted some essential workers, such as police and firefighters. Lefebvre says nurses feel very strongly that this raises a gender-equity issue: “Police and fire-fighting are male-dominated professions; nursing is female-dominated. All are essential services, and yet police and fire fighters are exempt.” The bill, she says, “is supported by the societal attitudes toward the devaluing of nursing as women’s work.” The province has said that “the purpose of this Act is to ensure that increases in public sector compensation reflect the fiscal situation of the Province, are consistent with the principles of responsible fiscal management and protect the sustainability of public services.”
And MacMillan says there’s still resistance to nurses asking questions, giving advice, and being part of the team. “Everyone needs to be able to say to a physician, ‘I don’t know why you’re ordering that. Are you sure you want 10 milligrams of that and not 15?’ Because that’s part of patient safety,” she explains. “And, as a nurse, you’re often the person who’s actually administering that medication or that treatment.”
Amie Varley, a registered nurse working in the Hamilton and Niagara area and co-host of The Gritty Nurse Podcast, says she was taught in nursing school that, while she could advocate for her patients, doctors had the final word. “So it's almost a double-edged sword,” she says. “You should advocate for your patient and use your expertise — but they don't teach you how to deal with a physician saying to you, ‘Well, it doesn't really matter what you say.’”
Varley, who graduated in 2010, says she sees remnants of the hierarchy enforced in the old hospital-training schools: “I'll never forget when we were at the nursing station and our preceptor [clinical instructor) said to us, ‘You know, if a physician comes by and needs the chair, you should get up, and you should give him that chair.’”