‘Vocational exploitation’ (1985), by Carl Pinel, Socialist Standard, May 1985

We document this ancient article on the situation of nurses in the mid-1980s by Carl Pinel. Sometimes you see clearer what is happening around you once you compare it with how it used to be. If you want to dive deeper down the past you can also read this review of Jonathan Neale’s splendid book ‘Memoirs of a callous picket’, on nurses’ strikes in the early 1980s. If you are more of a listening type, check out this new podcast on the Hayes hospital occupation in 1983!

Certain things stand out in Carl Pinel’s article. He speaks of the high levels of unemployment amongst nurses and midwives in the UK – levels to such an extent that they had to take HCA jobs. Well, that has changed! It is hard to imagine today how adamant the ruling class was in the early 1980s to break the power that the working class held during the 1970s – and unemployment was one of their main weapons. There is not only little unemployment amongst nurses today, our numbers have also more than doubled since then, from 350,000 in 1985 to nearly 750,000 today.

Another interesting change happened within the profession of nurses. Thank god, we don’t have to wear frilly hats anymore. And the union of nurses, the RCN, has also slightly changed! They wouldn’t allow men as members before the 1960s, HCAs were not admitted in the 1980s and they pledged not to go on strike ever. It is surprising that in the 1980s only 10% of all nurses were male, but even more surprising, that in 2024 it’s still only 11%! What’s going on there?

The article tells us that international nurses could only be promoted once the Home Office agreed. We are not sure whether that has changed much, as it is not easy to shift jobs as long as you are on a working visa. Read more about this in our previous article on international nurses.

And back then there was still residential accommodation provided for nurses! On the other hand, the author complains about the relatively meagre enhancements for working nights and weekends compared with other industrial workers. That has changed, too – nurses’ working conditions have improved, or rather, the conditions in most industries have drastically deteriorated. In the 1980s nurses went to support other workers’ struggles, from miners to printers. Today there are strikes by Amazon workers or at Royal Mail or the railways, but the tradition of supporting each other has been undermined.

All in all we can say that we are many more now, and potentially more powerful, and that we have to rediscover the sense of  working class solidarity!

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Nurses often cherish an illusion of “professionalism” despite the fact that they are subordinate to medical staff, are poorly paid, work shifts, weekends and public holidays (for which they receive lower rates of enhanced pay than most other workers), have poor working conditions in the majority of cases, and engage in stressful, demanding work within the rigid discipline of a status-conscious, hierarchical organisation.

Nursing qualifications are protected by law and it is a punishable offence to make a false claim to be a trained nurse. But there are two levels of qualified nurses. Registered nurses have qualifications which enable them to aspire to higher positions while enrolled nurses are unable to gain promotion beyond senior enrolled nurse grade. Doyal has pointed out that overseas nurses coming to Britain to train are encouraged to qualify as enrolled nurses only to find that their qualifications are not recognised in their own countries. She states:

“Nurses born overseas are over-represented in hospitals dealing with mental illness, mental handicap and geriatrics, and very few indeed are to be found in the “prestige” teaching hospitals. Overseas nurses are, therefore, clearly used to compensate for the shortage of British recruits into notoriously underpaid and often unpleasant work. Their role as a “reserve army” has recently been demonstrated with particular clarity by the fact that because of high levels of unemployment among British nurses, overseas nurses are increasingly being refused a renewal of their work permits.”

Nursing auxiliaries, although forming a substantial part of the work force, are untrained and unable to call themselves nurses.

The nurses’ professional organisation, the Royal College of Nursing, tends to be dominated by senior nurses and excludes nursing auxiliaries from membership. Indeed, prior to 1960 male nurses and enrolled nurses were also excluded. The RCN, in an attempt to maintain professional exclusiveness, has asked for nursing auxiliaries to be omitted from pay negotiations. The conservatism, elitism, avowal not to strike under any circumstances and tendency to concentrate on pay campaigns in favour of nursing administrators, have helped successive governments to divide the workforce and made their task of keeping wages low that much easier. Although in recent years the RCN has adopted a slightly more radical stance (possibly to avoid losing members to the trade unions representing nurses — NUPE. COHSE and NALGO) it remains a reactionary, divisive force.

A profession can be defined as an occupation requiring advanced education and nursing can reasonably be considered as such. However, the subordinate role of nursing has been demonstrated by the case of Derek Owen, a former staff nurse at Walsgrave Hospital. Coventry, who refused to participate in administering electroconvulsive treatment to a 76 year-old woman and was sacked. At the employment tribunal hearing Justice Popple well stated: “. . . it’s not the nurse who decides what treatment a patient would benefit from, but the doctor” (Nursing Times, 1984). Iliffe deals bluntly with the much vaunted professionalism in nursing:

“When nursing is restricted to mopping-up vomit, emptying bedpans and washing the bed-bound, it is only a special example of the caring role allotted to women, and nurses are therefore allotted the same autonomy as women generally. Nursing “professionalism”, therefore, aims at acquiring trade secrets (more politely called professional skills and knowledge) to give some nurses more autonomy, status and money. The evolution of special skills and knowledge necessitates a special education, with access to it restricted to ensure that the market is not overloaded with tradesmen.”

The appeal to professionalism is also used as an unsubtle form of blackmail to coerce nurses into docile conformism. The fact that trained nurses risk losing their qualifications through taking effective industrial action assists considerably in maintaining a compliant labour force.

When carrying out dirty work some form of protective clothing needs to be worn, but nurses insist on calling their overalls “uniforms” and wear useless frilly hats, perpetuating their domestic servant/hand maiden image. When their uniforms were compared with “. . . a plumber who insists on wearing a puce boiler suit, a purple beret, and his City and Guilds Certificate pinned to his chest!” (Pinel) there were horrified letters of protest in the nursing press. It is easy to dismiss the different coloured “uniforms” as a harmless, outdated tradition, but its perpetuation is designed to reinforce the rigid hierarchical structure and promote status consciousness. Servile, unquestioning workers accustomed to knowing their place within the organisation, dressed in a “uniform” designed for Victorian domestic servants, are easier to control.

Unlike other shift workers, nurses talk of their “duties”—a euphemism which disguises public holiday, weekend and night work often far in excess of shift workers in factories. It is only in the last twenty years that nurses have been able to receive extra pay for working unsocial hours and even now, in spite of being gradually increased over the years, nurses receive only time and one-third for Saturday, “unsocial hours’ and night work and time and two-thirds for Sunday and public holiday work. These rates lag well behind those paid in industry or, indeed, the rates paid to hospital ancillary staff.

With 10.000 nurses and midwives without jobs, a large pool of unemployed labour to fill nursing auxiliary vacancies, reduced demand for labour as hospitals are closed as a result of cutting resources to the health service and the weakness of trade unions during a recession have emboldened the government to try to abolish enhanced rates of pay for unsocial hours. Such a move, if successful, would cut the nurses’ standard of living and reverse twenty years of struggle to achieve pay conditions comparable with industrial workers.

Many hospitals were built in the Victorian era and are still in use today. Poor Law infirmaries, former workhouses and prison-like asylums still serve as district general hospitals, geriatric hospitals and psychiatric hospitals. With the cut-back in health service expenditure those hospitals that have survived closure have been patched up in a haphazard and piecemeal manner. The old buildings were never intended for modern nursing and condemn nurses and patients alike to substandard conditions. Very few buildings have been constructed to replace old hospitals. In the first seventeen years of the National Health Service only one new hospital was built. But as Widgery points out:

“…the size and location of the finished new hospitals often worsens rather than improves the national distribution of medical resources. The Royal Free in Hampstead is situated in the most affluent and healthy part of North London, while hospital facilities in the Northwest London industrial belt and in East London are being closed.”

Such closures oblige nurses to move or travel long distances to work.

Residential accommodation for nurses has been the subject of several campaigns to secure improvements. However, the government intends to sell off two thirds of the nurses’ homes (presumably that which is most profitable to speculators) and retain only a minimum stock of housing. Nurses, at the mercy of private landlords, would find their living standards declining further:

“Resident nurses are frequently subjected to a number of petty restrictions which would not be tolerated by private tenants elsewhere, and must represent one of the most pernicious forms of “tied cottage” arrangements in existence today.” (Pinel)

The lodging charges for resident nurses were due to increase by 5 per cent from 1 April 1985 although the government has announced that nurses’ wages must not rise by more than 3 per cent.

Nurse managers have opted out of nursing practice to “police” other nurses. They accept extra remuneration (or bribes) to enforce discipline, increase exploitation and punish their fellow workers, although as workers themselves they are dependent on the posts they hold for their livelihood. Male nurses, although making up less than 10 per cent of the nursing labour force, occupy one-third of the senior administrative posts, reflecting the sexist divisions of the broader society while the dearth of immigrants in senior posts is part of a deliberate policy for, as a Lanarkshire Health Board Memorandum stated: “No alien (Mauritian. Filipino. Chinese) person is to be promoted without the sanction of the Home Office” (Nursing Mirror, 1980).

During an industrial recession there is a surplus of labour and it is not so profitable to spend money conserving the workers’ health. Cuts in the health services and hospital closures have, therefore, weakened the bargaining power of nurses. But the divisive “professional” stance of nurses, their failure to recognise their class interests and to understand the exploitative role of capitalism have depressed the conditions of Britain’s 350.000 nurses and assisted successive governments in under-funding the health service.

Carl Pinel

References

Doyal, L. with Pennell. I. The Political Economy of Health. Pluto Press. 1979. p.206.
Iliffe. S. The NHS: a Picture of Health? Lawrence and Wishart, 1983. p. 147.
Nursing Mirror. News item. 151 (20) 4.
Nursing Times. News item. 80 (43) 5.
Pinel. C. “Are uniforms necessary?” Nursing Mirror. 14 November 1974, p.41.
Pinel. C. “‘Us’ and ‘them’ at work”. Nursing Mirror. 158 (10) 9.
Widgery. D. Health in Danger. Macmillan Press. 1979. pp. 52-53.