NURSES AND PROFESSSGNAUSM:
AN EMERGENCY ROOM CASE

Thesis for the Degree of M. A.
MICHIGAN STATE UNWERSEW
PAMELA i. ASCWENGL

1974 ‘

 

 

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ABSTRACT
NURSAS AND PROFESSIONALISM:
AN EMERGENCY ROOM CASE
BV

'4

Pamela Jane Schwingl

In a participant observation study of an emergency
room in a middle size, community hospital it was discov-
ered that nurses were actively supporting the idea of be—
comming professional emergency room nurses. Since this
concern with professionalism was not in keeping with re-
ports about the appeal of professionalization among rank
and file nurses, the researcher attempted to pinpoint par-
ticular features or predisposing factors within the work
setting which would contribute to an understanding of
why nurses would account for themselves as professionals.
The assembly line nature of work, and the emergency room
physicians' support of emergency medicine were cited as
major factors shaping the nurses' reSponse to work. In
addition an examination of the social characteristics,
age, education, and marital status of the nurses helped
to account for their enthusiasm about professionalization.
How work in an emergency room led to a tendency to cate-
gorize patients as apprOpriate or inapprOpriate was also

investigated.

YURSES AND PROFESSIONALISK:

AN ALERGENCY ROOfi CASE
BY

‘3
,v .
Pamela J? SchWingl

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements

for the degree of

:1 1"“. 3 T ER 0 jE‘“ KER T 3

Department of Soci0107y
1974

to my mother,

who was a strong woma

ii

TADLE CF CCN EN 3

Introduction

Nurses as Paramedicals: The Drive for
Professionalization

The Setting and the Study

Crisis and Routine, Excitement and Boredom
in the Emergency room

The Unpredictable Nature of Work in the
Emergency Room

The Routine Nature of Illness

Work and Meaning in the Emergency.hoom

The Organization of Work

Language and Neaning

Reaponses of the Nursing Staff towards Work
Professionalism and Emergency room Nurses
Footnotes

Appendix

Floor Plan of Emergency Room at Community
Hospital

iv

21
24
28

’3
C

42
48
56
64

69

ACKNOWLEDGNEJTS

I want to eXpress my gratitude to a number of
peOple who have been important throughout my graduate
education and who have helped me deveIOp both a sense of
who I am, and, not apart from this, a sense of what I be—
lieve to be worthy of concern and study in social life.

I wish to thank Dr. Barrie Thorne, my thesis advisor,
for providing substance and direction to the deveIOpment
of this thesis; and also for being enthusiastic and sup-
portive in all phases of my graduate education.

I also wish to thank the other members of my Master's
Committee, Dr. Bo Anderson and Dr. Marilyn Aronoff who
have provided several valuable insights on the material
in this thesis.

I would also like to thank my friends. Bob, Mark,
Claire, Mike, Sandy and Carolyn were around and listening
when I needed them.

And finally, it is with sincerity that I thank the
men and women who work in the emergency room in Community
HOSpital. Although their view of the emergency room might
be quite distinct from mine, I ave in no way intended to
invalidate the meaning they attach to their lives and to
their work. I only hone that I can better understand the
nature of work after this eXperience in the emergency room,

and hone that this thesis cancommunicate some of that un-

derstanding.

LIST OF E GURES

Figure 1.

Floor Plan of the Emergency room in Community
HOSpital

Introduction

 

When I began my fieldwork in the emergency room
of Community Hospital, I had little notion of what I
might discover. However, it wasn't long before I became
aware of a number of issues and problems which were im-
portant to the nurses who spent their time "holding down

the fort."1

Professionalization seemed to be one of these
issues, and one which the nursing staff Spent a great

deal of time discussing? I was soon able to see that much
of what happened in the emergency room between nurses and
patients, nurses and staff, as well as what occurred among
the nurses themselves could be understood in part by
examining how the nurses accounted for themselves as "pro-
fessionals." The more obvious methods of acCounting for
oneself such as one's demeanor or a vocal support of pro-
fessional nursing, as well as the more subtle methods,
such as a concern with one's professional time, indicated
that the issue of professionalism was a salient one for
several of the nurses.

During this time I was searching the nursing journals
and the existing sociological literature on nurses in
order to discover how the issue of professionalization
and professionalism among nurses was being treated. In-
terestingly enough it became apparent that the nursing

leaders who were writing much of the literature, were also

the peOple who were pushing for professionalization;

and in fact, the rank and file nurses were only concerned
in a very minor way with professionalization, or with the
idea of becoming professionals.3 The studies which ex-
amined how the rank and file regard professionalization
were primarily attitudinal in nature, and only indicated
that the nurses with professional degrees in nursing dif-
fered from nurses with technical degrees only in terms

4

of their "professional attitude." It was at this point
that my interest was aroused; why were the nurses in the
emergency room so concerned with themselves as professionals?
Was it only a difference in education? Obviously they were
not the educators or leaders of the field, nor did they

all have "professional degrees."

Ky attention strated to shift towards examining
particular aspects of the work setting. By taking a good
look at the conditions of work and the organization of
the emergency room, I decided that I might be able to dis-
cover what it was that made the idea of professionalism
appealing to this particular group of nurses. In this
way I could also understand w at a "professional attitude"
meant in a particular setting.

With these ideas in mind then, I have attempted to
map out the "prediSposing factors" which existed in the
emergency room milieu, and to specify who supported pro~
fessionalism and who did not, and what this meant for the

day to day negotiations of work. As an introduction to

the text, I have included a discussion of nurses within
the medical "paraprofessional" hierarchy, and what pro—
fessionalism has meant for both the leaders and the

rank and file within the occupation of nursing.

Nurses as Paramedicals: The Drive for Professionalization

 

The organization of work and knowledge has undergone
extraordinary changes in the last century. The increasing
number of universities and university-trained students,
combined with technological advances which have come about
since the mid-1800's have created a steady proliferation
of new occupations. The kind of knowledge required in
many of these occupations is highly Specialized and esoteric;
some observers believe this increasing specialization is
making society more and more illiterate, creating a situa—
tion where a single person in one occupation couldn't pos-
sibly know what goes on in other occupations without taking
several courses of advanced knowledge in many areas.

This proliferation of esoteric specialties is not
confined to areas like computers for example, which are
products of this century's technology; there is an increasing
differentiation of labor in traditional areas of knowledge
as well, such as in law or in medicine. In the case of med-
icine, the division of labor is somewhat unique;6the vast
numbers of new medical occupations are organized around and
controlled by a central dominant professionj' These para—
medical occupations perform many of the tasks which once
were accomplished solely by physicians, while doctors have
gone on to practice more refined techniques and to continue

in their primary function of diagnosing and prescribing.

\J

The paramedical occupations are characterized by a lack
of autonomy; they are tightly controlled by the medical
profession, and they form a rigid hierarchy of jobs which
depend on, and take orders from physicians. These jobs
for the most part tend to offer little chance of mobility
to those who choose to be trained for them. Persons
trained to be X-ray technicians are not encouraged to ac-
quire the new training necessary to be interns or doctors,
nor are medical technologists likely to be found seeking
better Opportunities within the occupational group of
electroencephalograph technicians, for example. There is
little on-the-job mobility among occupations; to change
one's position in the hierarchy, one must leave the hospital
and take up more formal schooling. As a result of such
organization, paramedical groups are isolated, and health
workers are offered little Opportunity or incentive to go
further within the field of medicine.

Although it calls itself a profession, nursing is
located within the health care hierarchy. Like most para-
medical occupations, nursing deveIOped by taking over tasks
which another occupation (in this case, physicians) no long-
er wished to perform. In turn, nursing has given over a
number of tasks to occupations of lower status in the medi-
cal work system. For example, nurses once performed social
services and activities for patients, and cleaned beds and
sterilized bedpans, as well as maintaining records of ad-

missions, deaths, and discharges. Now there are medical

social workers, LPNs, recreation therapists, central

supply technicians, and medical librarians, to name a

few who perform the same duties. Nurses themselves have
taken over several functions which were performed only by
doctors, such as diSpensing medications, taking blood pres-
sures or preparing and setting up intravenous feedings.

In the last few years another Specialty, the physician's
assistant, has deveIOped to take over even more of the
physicians tasks.

Differentiation of levels has also occured within
the occupational group of nurses. Over the years several
categories of nurses have evolved, differentiated by length
and place of training: diploma school graduates, Baccalaur-
eatte (four year) graduates, Masters degree nurses, two-
year technical RNS (registered nurses), and LPNs (licensed
practical nurses) who are usually trained in technical pro-
grams lasting not longer than one year.

The frequent reorganization of tasks among paramedical
groups, as well as the steady deveIOpment of newer Special—
ties and subSpecialties which impinge on the territories
of older occupations, may threaten the status of a parti-
cular occupation in the medical hierarchy. Leaders of
particular occupations see that it is in their interest to
safeguard their own niche, or to claim an exclusive mandate
over a particular area of workl.O Claiming professional rank
is a powerful means for getting ahead in the race for status,
prestige, and monetary gains within the medical hierarchy.

However, to buttress this claim, the occupations involved

have to participate to varying degrees in the manipula-
tion of the symbols of professionalism. Journals are
filled with articles which argue how closely a given
occupation meets the standards of the traditionally de—
fined professions ( e.g., that the occupation has a unique
body of knowledge, and a code of ethics). Location of
training within colleges and universities is eagerly sought;
clothing and demeanor become the object of close attention;
licensing proCedures are established to give the group
control of its boundaries; and often associations are formed
which proclaim and push the professional status of the
occupation.

To avoid the mistake of viewing any of these occupations
as monolithic entities, it is important to closely examine
the movement toward professionalization; who, within a
given occupation advocates becoming a profession, and for
what reasons?llAmong nurses, the leaders and educators in
the field (including those with the most advanced degrees),
appear to be the peOple most caught up in the drive for
professionalization. It is in their interest to see that
the occupation gets its fair share of the goodies; not
only are they able to perceive the distribution of resources
within the various institutions they're located in, but
also they know that autonomy of the occupation brings pres—
tige to themselves and to their cohorts. These peOple are
also those who have received much "professional" training
and education, and are eager to carry on the tradition.

By pushing for professionalization of the occupation, the

the leaders can gain autonomy from physicians, and can
help protect the occupation from further impingement on
its territory from above (for example, from peOple such
as physician assistants), or from below (by occupations
of non-nursing personnel). Thus to understand the drive
for professionalization, it seems important to understand
the position of nursing in the medical hierarchy. Pro-
fessionalization in this sense is a powerful tool in the
struggle among leaders of the various paramedical groups.

If it is the leaders of the field who are most caught
up in pushing for the professionalization of the occupation,
then how do the rank and file relate to this issue? It
has been reported that the rank and file are only marginal-
ly interested, and on the whole care little about the is-
sue of professionalization.l2Part of the reason for this
discrepancy might be ascertained by investigating how
nursing fares both economically and meaningfully to the
individual nurse at the point of entry into the field.

In order to keep the occupation of nursing in the
running within the medical hierarchy, it is important that
there be large numbers of nurses. As long as this condi-
tion exists, the occupation has a better chance of re-
maining unthreatened by non-nursing paramedical occupations.
Thus nursing leaders have been recruiting large numbers of
women into the field to keep the number of available nurses

13

rather high, although not oversupplied. This of course re-
sults in low wages for any individual nurse, since the sup-

ply of nurses will at least equal the demand for them. This

presents a problem for potential recruits who know that

in order to get a degree, in many cases they will have

to commit themselves to a number of years being trained for
the occupation. In other words, the cost of becoming a
nurse frequently outwighs the economic gains. This is

where professionalism gets some of its lure -- by presenting
the occupation as a profession whiCh entails Special commit-
ment, and dedication and status, nursing leaders can attract
women who might otherwise choose a more lucrative field.

The lure of the occupational pamphlets proclaiming reSpon—
sibility and autonomy for the graduates who complete their
programs, and the uniforms and "professional" demeanor dis-
played by the representatives of the occupation probably

are appealing to many women Seeking a career. Throughout
their education, (at least for RNS) training includes talk
of professional ethics, codes, demeanor, and reSponsibility.
What occurs after the neOphyte starts to work however, helps
explain the high turnover and attrition rates among nurses,
and the fact that only about one third of the trained reg—
istered nurses actually work.14

"Reality shock is a term Everett C. Hughes used to

describe the disjunction which nursing graduates eXperience
between their eXpectations and the actual reality of the job.
S<mnehow the job doesn't match its description; the responsi-
bility isn't as great as their eXpectations; and the routine
Imrture of the job doesn't give the graduates the sense of

ex<2itement and responsibility which they anticipated. In

10

other words, the promise of professionalization remains
on a theoretical level, while the bureacratization and
routinization of hOSpital life becomes the reality.

For many nursing graduates the greatest shock
is probably the distance that the nurse must maintain and
is encouraged to maintain from the patient. In fact those
nurses with the most status are the managerial nurses,
those furthest away from patient care, while nurses aides,
women with little or no formal training, have the most
contact with patients. For the most part, graduates have
few choices once they have entered the system. Once on
the job, many nurses redefine and modify the ideals which
they learned in schoolgisThus, instead of concentrating on
caring for patients directly, energy and attention is focused
on activities designed to meet bureacratic standards, such
as-good record—keeping or efficient use of time. Reports
of nursingyéhow that nurses are involved in very little
decision making of a "professional" nature, and are frequent—
ly relegated to jobs which have little to do with direct
patient carefiiaflhen nurses aren't engaged in doing particu-
lar tasks, free time is often spent with other staff rather
than in caring for patients:19

In this study of nurses in a hospital emergency room,
flit became apparent that the work done by nurses was narrow
ill SCOpe; the care given to the patients was organized in
an assembly—line fashion. Patients were quickly treated

andi nurses rarely saw them a ain or found out how effective

their treatment had been. Work was done efficiently and

ll

quickly, and nurses were not able to Spend extra time
with patients; if they had though they would like to do
so before they started working in the emergency room,

the contingencies of the job quickly changed their minds.
If this is the reality of work on the job, then what can
"professionalism" mean to nurses who are engaged in work
which is routine and which demands little “professional
decision making? The 'ssue of professionalization of

the occupation, at least in the terms in which it is car-
ried on by the leaders of the field, seems far removed
from the eXperience of the nurse on the job. In the

. . . . 20
study which follows, the nurses in Community Hospital
will be Shown as attempting to wrest some autonomy from
physicians in the emergency room; they have an idea that
"being professional" will bring some reward. Whether
they find this a satisfying g al remains to be seen;
however what will be examined is how they go about ne-
gotiating their position as staff in an emergency room

setting.

The Setting and the Study

 

The Emergency room unit which was studied is part
of Community Hospital, a moderate sized acute care hos-
pital which is located in a capitol city of a large mid-
western state, and which is privately supported and one of
four hospitals serving the peOple in this particular com-
munity. As in most community hospitals, private physicians
who have admitting privileges play a major role in the hos-
pital, and although there are some ties to a nearby univer-
sity medical school, residents and interns are not common-
ly seen in the hOSpital setting. The hospital is located
in a predominantly black, poor, industrialized area of the
city; however, because private physicians throughout the
city make use of admitting privileges, patients using the
facilities of Community include wealthier, white patients
from different parts of the city, as well as Chicano and
white working class peOple who make their living working
in the factories nearby.

The emergency room is somewhat unique compared to
the emergency services which are offered in most commun-
ity hospitals. Instead of being directly run by the hos-
pital's own resident staff of physicians, the ERZat Com-
munity is leased and Operated by a group of private physi-
cians who make this their own "practice" of sorts. Trad-

itionally the "pit," or the emergency room, has been the

12

13

last stOp for interns and residents before they went

on to the more lucrative and prestigous private.practices.
However, there is an increasing tendency for physicians

to regard emergency practice as varied and exciting,

and by leasing the service out to a few physicians the
practice has become quite lucrative for both the doctors
and the hOSpital. Although this hasn't become a common
practice, emergency specialists are becoming more numerous
over the last few years, and there are more programs devel-
Oping in medical schools which include courses on emergency
practice. Along with this trend there have arisen associa-
tions of emergency physicians and journals written for prac-
ticing emergency doctors?

In this particular emergency room there existed a con-
sciousness of this arrangement as being unique, and some-
what "better" than the traditional arrangement which exist-
ed in the other hOSpitals in the city. The doctors them-
selves would comment occasionally that they felt they were
running a "faster, more efficient" service than the other
RES in the city; and also they would comment upon "what a
good business" they had here for themselves. An important
point about this particular type of organization is that the
doctors, unlike those who merely had admitting privileges
in the hOSpital, were physically and spacially bound to
the emergency roomfI3They had rotating twelve hour shifts
and were integrally involved in the administration of the ER.

For‘the doctors, the ER was a business enterprise and they

14

were concerned that it be successful; they have a stake
in the develOpment of its good reputation. They were con—
cerned with being good "emergency physicians," and that
they know "their stuff." The Specialty of practicing emer—
gency room medicine was important in itself, not as a pass-
ing "experience" which was important for interns or residents
who might temporarily staff the ER. The notion that this
was a Special kind of practice, or a Special kind of care
was communicated to all of the staff, and, in fact, might
be cited as part of the reason for the nurses' own concern
with themselves as a Special group doing "emergency nursing."
In Community there are three Shifts which must be
staffed: days (7am to 3pm), afternoons (3pm to llpm), and
nights (llpm to 7am). Each Shift has its own nursing staff;
in other words there is a minimum exchange of nurses between
shifts. This is not true for orderlies, who often Switch
shifts among themselves. Clerks also have regular Shifts,
but frequently move in and out of different time Slots. A-
mong doctors there is much changing of work times, so that
the same doctor never works on any one shift for any length
of time. AS a result, nursing and clerical staff all work
with all of the doctors at some time during a given month.
Although there is some fluidity of peOple over Shifts, each
Shift maintains a loose definition of itself as a unit.
-Parties are sometimes thrown by the "day Shift" staff on their
time off; and once a nurse on the "night shift" mentioned

that She had been at a party which had been held by the

15

"night crew."

The peOple who staff the various Shifts in the ER
differ in terms of their age and lifestyle depending upon
whether they work days or nights. Nurses who work on the
day Shift are considered by those who work on the after-
noon and night Shift to be "homebodies" and are usually
older, married and have children in School. One RN who
works on afternoons referred to the "day peOple" as those
who really aren't interested in working or nursing as a
"career," but inStead they're interested in getting away
from their kids. The "day peOple" however view the young-
er nurses who work on the afternoon and evening Shifts as
ambitious, if not a bit over-enthusiastic. The afternoon
and evening shift both consist of nurses who are predominant-
ly Single, young, and recently out of nursing School. They
usually talk less about "home"-type issues, (husband and
children), and instead often talk about nursing, other
nurses, or activities they engage in during off-hours (ski-
ing, camping, sewing, crafts, or sailing).24

In Community there is rarely ever any exchange of
staff between this part of the hOSpital (ER) and the floors,
although the emergency room does use the technical services
of the hOSpital, such as the laboratory and X—ray. At any
time in the emergency room one could expect to see any of
'the emergency room staff, as well as various technical, cus-
todial, or administrative peOple moving in and out, perform-
ing their various tasks. There are less of these peOple

at night, although the lab technician, the cardio technician,

25

and the X-ray technician who work at night usually stOp
by for coffee and conversation; in fact these peOple
develOp close ties with the night crew in ER, at least
more so than those technicians who work during the day.26
Although there is movement between the ER and the rest
of the hospital, there is never an exchange of working
staff members among the various departments and the
emergency room. That is, nurses or orderlies and clerks
who work "on the floor" never work in the emergency room,
nor do emergency staff work on the floors, even if either
department needs extra help. In part this iS a result
of the autonomous administrative nature of the emergency
room; however, this organization in turn effects the rela-
tionships which develOp between nurses in different de-
partments. There is little Opportunity for nurses to get
to know one another; usually if an ER nurse happens to
know another nurse on the floor, it is because they at-
tended school together, or there is a personal relation-
ship ( a friend of my brother's friend...) between them.
Nurses in the emergency room usually eat lunch with other
ER staff (including doctors and clerks). This differs
from the usual pattern in this hOSpital -— nurses eating
with nurses, doctors with doctors, clerks with clerks.
The actual physical setting of the emergency room
(/Hypendix A) is an important consideration Since the posi-
tifinfling of the various personnel seems to shape the pos—

Sibjfllities for interaction among them. For example, the

 

17

doctors' room, which was set away from the nurses'
station, provided a place in which the physician on duty
could rest while there were no patients to be treated.
Thus the doctor could retreat into a private Space during
slow times while nurses, clerks, and orderlies had to
share a physically small area and were faced with the
possibility of relating to each other during such times.
AS a result, slow periods were times when staff would talk
among themselves about any number of tepics, and doctors
would rarely be included as participants, although oc-
casionally they would be subjects of the conversation.

The admitting clerk was also physically separated from

the nurses' station by a glass partition which prevented
her from hearing or seeing clearly what went on on the
other Side. This situation, along with the fact that the
clerk was administratively autonomous from the other staff
members in the emergency room, made her less a part of

what went on among the nurses, orderlies, and ward clerks.

The observations upon which this thesis is based
were obtained over an eight month period during which I
worked as an admitting clerk on the weekend night Shift in
the emergency room. For several weeks, I worked extra time
during the regular day shift, so I was able to get a sense
of how the weekend night shift differed from the other
Shifts. However this analysis is based primarily on ob-
servations and conversations which occured during the night

shift, and will be qualified with data from the other shifts

when necessary.

Because I was a working employee in the emergency

room, observations had to be recorded at times when I

as not working. Often I was able to jot down notes while
working if the ER was Slow, but usually I wrote notes after
leaving the hospital. I tried to observe everything going
on in the emergency room -- conversations between staff

and patients, exchanges between doctors and nurses, conver-
sations which I myself had with various patients and staff
members, and the kinds of verbal and non—verbal interaction
which took place between ambulance drivers and police,
staff and patients. I also tried to become aware of my

own socialization as an emergency room employee, and the
changes which I eXperienced working in a place where crisis
and tragedy were a matter of routine.

After working awhile in the ER, I realized that all
that went on there just couldn't be recorded; thus my fo-
cus narrowed, and I started concentrating on the nurses who
worked there and how they made sense of the emergency room.
Because of the constraints of my own job as admitting clerk
however, I was not always able to be part of what occured
inside of the treatment rooms, or the nurses' station. In
addition, my role as part-time worker, and weekend employee
at that, limited the extent to which I could become an
insider, and understand the dynamics of the relationships

of workers inside the ER (Appendix B).

19

The negotiations between myself and the staff
which took place in order to establish "who I was," are
documented completely in the second appendix to this re-
port. It is hard to say to what extent my identity alter—
ed or distorted what transpired between myself and the
staff. It seems important however to state that I prob-
ably was not considered a member of the group, as several
of the admitting clerks were; rather, because of my status
as a student, part-time worker, and medically naive, trust-
ing persong7I was considered to be an outsider. Having
taken the job as admitting clerk, access was not immediate-
ly problematic. However, the suSpicion which existed im-
mediately about myself, made it impossible to disclose
the fact that I was a researcher; guilt, in addition to
the contingencies which existed to make "data—gathering"
problematic, combined to make it difficult for me to gat-
her as much information as I would have considered desirable.

With these qualifying factors in mind then, I will
go on in the next section, to describe one group of factors
which seemed to contribute to the appeal of professional-
ism among nurses in the emergency room. The organization
of work, the contingencies of boredom and crises will
set the stage for an understanding of the setting in which

nurses account for themselves as "professionals."

Crisis and the Routine, Excitement and Boredom in the
Emergency Room

 

Most pecple imagine emergency rooms to be exciting,
efficient, or tragic places where life and death decisions
are made by white-clad men and women while ambulances
scream in the background, and beams from their rotating
lights bounce off walls in narrow hallways. The imagery
suggests a place of continual crises lived out by individuals
who worry in waiting rooms and later in rooms divided by
gauze curtains.

This is the picture of the emergency room I had while
I was considering taking a job as emergency room admitting
clerk in Community HOSpital, a medium size private hOSpital;
I wondered how I could face these crises, knowing that I
became weak at the thought of a simple injury. I remember
feeling panic during the first few nights ofvork, whenever
the doors to the ER would swing Open; I also remember sitting
at my desk, facing these doors, and preparing myself for the
worst possible shock. It was interesting to watch not only
my own initial reactions to the ER, but also to listen to
and observe the responses of other new staff members, parti-
cularly new nurses who were hired after I had been working
for some time. Although some of these peOple had eXperience
in nursing, they seemed very apprehensive about working in
this particular area of the hospital. Allysongaa newly hired

RN, paced back and forth in the nurses' station, and ner-

20

21

vously peered out through the waiting room toward the
doors whenever they Opened to admit a patient. Although
Allyson had worked in a hospital before, She initially
eXpressed concern that emergencies "made (her) nervous,"
and that "the ambulances always made (her) remember TV
programs about emergency rooms."

After working in the ER for awhile however, I (and
apparently other novices as well) began to see the events
of the emergency room in a different light. The image of
the ER as a place where life and death decisions are con-
stantly being negotiated does not convey the total reality
of the ER for the peOple who have become enmeshed in its
day—to-day activity. Rather, the peOple who work in the
ER find themselves dealing not only with crisis, but also
with boredom and routine; times when patients complain of
illnesses hich are less than dramatic, and times when there
are only a few patients in the emergency room. Thus to
describe the reality of the emergency room from the point
of view of the peOple who work there,\muld require an exam-
ination of how the dimensions of work combine to create a
milieu in which elements of boredom and tension, crisis
and routine exist side-by-side.

The Unpredictable Nature of Work in the Emergency Room

 

Work in the emergency room, eSpecially when one con-
trasts it, for example, with work done in chronic care
wards, is highly unpredictable?9 Staff members have dif-
ficulty determining how busy they might be at the begin-

ning of a particular shift; they cannot predict what

types of patients will come into the emergency room
for treatment, and what kind of work they will therefore
be engaged in. Before a shift begins, the nurses, order-
lies and ward clerks usually gather in the hOSpital cafe-
teria for coffee and some conversation. Invariably some-
one will wonder out loud how the ER has been going tonight,
whether it was busy or slow, and what the next eight hours
might hold. During the time I worked, it struck me as
quite unusual that I was never able'b predict how busy an
evening would be, nor was I ever able to establish a reliable
pattern or formula for determining what were busy times of
the day or week. Once I casually mentioned this to some
of the nurses and they agreed with me,saying that "you just
never know around here what's going to happen next." 30
All of the peOple who work in the ER regularly evaluate
their shift or work-day in terms of how busy theyvere.
Counting the actual numbers of patients who come into the
ER for treatment is one way that they gauge how much work
was done on a shift. "How many patients have we seen?"
is a tandard question asked several times during any shift.
This will usually be asked of the admitting clerk whose
task is to keep count of the number of patients who come
in. The number is a measure of the work accomplished; for
example, on the day shift, 40 is seen as a reasonable num-
ber of patients, whereas during the night, this decreases
to 20 or 25.
Each type of worker has different standards for assessing

work done. For an admitting clerk it is important to know

how many admissions were processed, for this indicates
how busy one has been during a shift. To tell the ad-
mitting clerk who relieves me in the morning that I had
"six emergency admissions, nd six 'directs'" that night,
means that I was very busy, and she will probably respond
in a way indicating that she agrees this is a lot of work.
Nurses will recount how many charts were lined up along
the counter at one time during the night, or how many times
they were awakened to see patients, or they will refer to
the number of "serious" patients they saw in a night.
Orderlies count the number of patients they have had to
take "upstairs" while ward clerks count the number of peOple
sent to X-ray.
On slow nights or during slow periods of a shift

when there is little work to do there is a definite urge
to complain of boredom. One slow night when it was parti-
cularly dull in the ER, Leanne, an RN who worked part-time
in the ER, told a story to myself and the ward clerk and
orderly about how she had decided to become a nurse. Her
mother had been killed in an auto accident when she was a
child, and she remembered coming to an emergency room and
watching nurses and doctors "trying to save (her) mothers
life." She promised herself that she would become a nurse
too, in order to do the same for others. Her story con-
cluded however, with her Spreading her arms and looking
around in the nurses' station,

"little did I know that this is what it would

be like; just look at us, it sure isn't as
exciting as it looked then!"

Along with the urge to complain of boredom, how—
ever, is a belief that one must not complain too much for
fear that the emergency roomvould get a "rush of bad stuff."
Staff members who complain that it isn't exciting here will
usually be reminded that they shouldn't say anything or
they'll'be sorry.‘ In the face of nothing to do in the
ER, there is always the apprehension that there could be
too much to do. The nervousness which one initially feels
about work in the ER as a result of its unpredictable nature,
eventually becomes transformed into a cynicism which char-
acterizes those who have worked in the ER for awhile. Be-
coming socialized into the work milieu in the ER means that
one will stand off from the crises, or protect oneself

from the unpredictability
The Routine Nature of Illness in the Emergency room

Work for the staff however, is not perceived purely
in terms of the amount ofvmrk or the numbers of patients
who are seen on any shift. Work is also evaluated in terms
of the nature of the problems which one must care for.
The work of the ER (TV programs notwithstanding), does not
always involve decisions of life and death. Many of the
cases are far less dramatic. At any time of the day or
night the chairs lining the walls of the ER waiting room
might be crowded with patients who have come to seek care
for colds, sore backs, or headaChes -- problems which might
otherwise be taken care of by the family physician or at

l .
the clinic;3 One evening Leanne cynically mentioned that

working here was like working in a doctor's office,
except for the "emergencies." She added,

"the peOple on days actually see a lot more

than we do at night. That's when there are

more 'emergencies;' at night peOple come in

who aren't able to get hold of their regular

doctors."

The peOple who work in the ER on the day shift probably
don't eXperience many more "emergencies" however, than
those who work at night; an excerpt from fieldnotes
taken while working on a day shift illustrates this:

"After working here today I am astounded at

the number of peOple who are using this place

as_a clinic. There certainly isn't as much

excitement here as there is during the night;

there are only a lot of babies crying and

peOple coming in for "rechecks" on sutures and

casts; I guess that there must be a difference

on different shifts or maybe it's the daylight

which makes this place seem a lot more routine!

(Marian, an RN, has just remarked that she

was really not in the mood again to waster her

time with 'this nonsense'.)

There is consensus among the staff that "routine"
complaints are something of a waste of time; nurses will
half-jokingly admonish me for "bringing in all this
stuff," since it is I, as admissions clerk, who "sends
the patients back" for treatment. Allyson, who at firSt
greeted every patient with a smile, after awhile in the
ER took on the cynicism toward the routine patients which
was characteristic of the rest of the staff. She would

place her hand on her hip and shake her head when a patient

complained of some routine ailment:

"why don't they leave us alone; if they go back
to bed they'll probably feel better in the morn-
ing."

26

Jane, another Rn, often comments quite seriously that
she really hates this kind of routine work.

On the nights when there are serious emergencies, and
a staff member asks how many patients have been through the
ER, she may be surprised to hear that the number is so low;

"it seemed like we had a hundred patients tonight;
those few bad ones really kept us busy,"

and on other nights the number seems high:
"I'm surprised we saw that many; it was all that

little stuff though; you can certainly spend a
lot of time doing nothing."

32

Hughes, in an essay on work, mentions that peOple who
have experience with crisis tend to believe that peOple ex—
aggerate their problems. After seeing a great range of ill—
ness and injury, the staff actually perceive the less ser-
ious complaints to be trivial, and the peOple who bring them,
to be silly and intrusive.

Nurses and staff vary in the degree to which they
view these routine cases as a waste of time or as "inap-
prOpriate." This has to do, in part with how narrowly they
define the function of the emergency room, either as a place
for "real emergencies," or as a place which will inevitably
be "clinic—like." The nurses who are more involved in de-
fining themselves as "professionals," are also more likely
to see the function of the emergency room as a place for
"emergencies only? whereas their less professional colleagues
tend to accept the idea that the ER will be similar to a
clinic or doctors office. Why patients are seen as inappro-

priate by some staff members and less so by others is an

27

important issue. How individuals evaluate their work and
the peOple they deal with has to do with how they perceive
the manner in whichtheir work fits with their life, and
the meanings which they attach to their role as nurse or
doctor, ward clerk or orderly.33 By looking closely at how
work is organized in the emergency room, we can begin to
understand the actual contingencies of work for various
workers, as well as the meanings which workers attach to

their work and to their clients.

Work and Meaning in the Emergency Room

The unpredictable nature of events in the emergency
room requires a highly structured organization of peOple
who can efficiently deal with the entire range of prob-
lems or emergencies which patients bring to them. Crises
must be stripped of their unique character, and must be
handled as instances of a type or category of illness or
injury; that is, they must be dealt with in a rational
way by peOple who are organized to care for the uneXpect-
ed4y4For these peOple who work in the ER, crises as well
as "routine cases," become routinized and subjected to
the bureacratic organization of tasks. There is little
room for heroic deeds here; rather the constraints of
the task structure make it nearly impossible for peOple
to perform work outside of that which is defined as their
"job." Instead of "saving lives" staff members are act-
ually involved in performing their narrow function as
quickly and efficiently as possible; even doctors, the
peOple who are supposedly most free with reSpect to the
boundaries of their work, are constrained in this setting.
An examination of the organization of the work which the
various staff members do in the emergency room will give
the reader some idea of l) the sc0pe of care in which
any individual staff member is actually involved, and 2)
how particular patients and events in the emergency room

are defined by the staff who work there.

28

29

The Organization of work in the Emergency room

Each person who works in the ER has particular
tasks to perform for the care of any given patient. The
tasks or techniques which are performed are standardized
for particular categories of illness and injury. For
example, a patient who has a burned arm will require the
performance of particular tasks which will alleviate the
pain of the burn and which will help allay scarring; on
the other hand, a patient who complains of what he be-
lieves to be a broken leg will require the staff to as-
certain if the leg is in fact broken, and if it is, to
prepare the leg to be set and wrapped. Each of these
tasks or groups of tasks are assigned to particular peo-
ple on the ER staff, i.e., clerks (admitting and ward
clerks), orderlies, Licensed Practical Nurses (LPNs),
Registered Nurses (RNs), and doctors. The doctor is the
central person in the organization of work. It is he
who performs the final diagnosis and who treats the pa-
tient; all other peOple in the emergency room and those
whose services are called upon who do not work primarily
in the ER (lab technicians, X-ray technicians, etc.) aid
in gathering information to carry out the diagnostic func-
tion, and perform most of the auxilliary tasks which are
required to diagnose and treat patients. The doctor has
ultimate responsibility although the information which he
works with has been filtered through these other peOple.

Each patient who admits himself for treatment inihe ER

30

starts in motion a process of information gathering and
"treatment." In order to understand the organization of
work in the ER then, it will help to examine the nature
of the jobs for the various categories of staff peOple
who work there.

The job of the admitting clerk is considered to
be purely clerical in nature, however there are other
elements of the job which can be thought of as crudely
diagnostic functions or "buffer" functions which the admit-
ting clerk engages in. As a "paperworker" hired by the
Admitting Department of the hospital, rather than direct—
ly by the emergency room (as the other staff members who
work in the ER), the admitting clerk generally functions
to obtain information about all patients who come into
the emergency room.3§Jokes about hospitals oftencsnter
around how staff peOple seem more concerned about getting
patients' social security numbers than actually helping
them to get treated. In part,'Me admitting clerk is train-
ed to concentrate on numbers, paper work, insurance forms,
and charts. Her job is organized around finding out in-
formation from peOple who often consider giving it to be
unimportant, mundane, or trivial. Although formal train-
ing of the admitting clerk includes only attention to
Paperwork, the work also involves acquiring sensitive inter—
actixxnal skills which enable the clerk to carry on the
function.of filling out forms for peOple who are uncomfort-
able, ‘very ill, or even dead. In addition to these skills

relatexi to dealing with patients, the admitting clerk must

31

also acquire the knowledge necessary to "screen" patients
or to crudely diagnose a patient's condition in order to
let the rest of the staff know what problems they will
be dealing with. This might include allowing a patient
to be treated immediately if judged to be "serious" e-
nough, or if the patient is not considered to be ill
enough to require immediate attention, he is told "to wait,"
while the staff deals with the more "important things."
In a sense the clerk acts as the first person in a series
of "buffers" between the patient and the doctor, allowing
only certain patients and information to reach him.36

When a patient enters the emergency room theeflmitting
clerk quickly assesses his condition. For cases which are
extremely and unquestionably serious, for example heart
attacks or stabbings, the admitting clerk tells the patient
to go "right through the doors" (swinging doors which Open
into the treatment area of the emergency room). In such
instances she is not able to get the information at the
desk, so she has to go into the treatment room where the
patient has been situated to get the information she needs.
These are often very touchy situations and require skillful
handling to avoid annoying the patient too much while get—
ting the information which is needed to "process" him.

It took me awhile before I was able to feel even a
ljflrtle comfortable going into the treatment roomwhere a
seriously ill or injured patient had been situated. The

nursens seemed to understand that getting information from

32

such a person is touchy, and theyvould at first help me
find out what I needed to know about the patient. After
working in the ER awhile however, I was eXpected to get
the information myself; and only if the patient was un—
conscious or dead, was I able to avoid having to ask him
all the questions which would be asked of someone with a
headcold. The job was made considerably easier if the pa-
tient was accompanied by a relative or friend who could tell
me what I needed to know. However, even with these peOple
it was necessary to follow some rules in order to avoid
looking over-eager to fill out forms, and not sorry enough
about the patient .37

For peOple who came into the emergency mom complaining
Of a toothache or a headcold, the sequence of interaction
between the admitting clerk and the patient was different,
and the process Of Obtaining information wasn't as sensitive
an issue. The patients had to give the admitting clerk
information about themselves at the desk; this included
name, address, insurance, place of work, birthdate, marital
status, and regular physician. After this information was
Obtained, the clerk would tell the patients to have a seat
until'called.

Neither of the above types of cases presented the
admitting clerk with a situation in which she had to make
a decipflon.about what to tell these peOple when they came
into the emergency room. In contrast to those Obviously
sericnzs, or numdane cases there were several types Of pa—

tientns who were neither Obviously critically ill, nor

33

casually seeking help for a problem which might otherwise
go away in a day or so. These patients experienced quite
intense pain or discomfort and felt that their problem

was serious enough to warrant immediate attention (al-
though frequently the staff believed that they probably
could have waited before being seen). Stalling techniques
were required in such instances, since the staff didn't
want to be bothered with these peOple for one reason or
another, and the clerk had to keep these patients from
intruding too much on the staff's time or energy. This
was Often a very difficult feat to perform if the patient
was particularly insistent upon being seen, or if the staff
was particularly insistent upon not seeing the patient im-
mediately.38

Although the admissions job requires some diagnostic
and interactional skills, for the most part there exists the
ever present reality of the paper work which has to be done
for all patients seen in the emergency room, and extra work
for all patients admitted into the hospital. There are
constraints on the admitting clerk from going beyond these
particular functions outlined above however, and Often
as the admitting clerk I found myself feeling a bit frus-
trated about the sc0pe of work to which I was relegated.

One night when the emergency room was especially busy
and "the nursing staff was short, I remember feeling helpless
SittiILg at my desk knowing there was nothing I could do to
help either patients or staff. I knew that many Of the

jObS thich they were doing weren't completely medical in

34

nature, yet I had not learned, nor had I an Opportunity

to learn of what those jobs consisted. For example,
valuables of patients admitted to the hOSpital had to be
placed in envelOpes and recorded on Special forms for

this purpose; this is a job which requires a considerable
amount of time, yet it is one which only nurses are "per-
mitted" to do; even had I known how to do this job, I
wouldn't have been allowed to do it. Rather I had been
trained to do a particular sort of paper work, the type re-
lated to admitting and "processing" patients. In training
for the job I asked nurses or orderlies several times about
how they performed a particular task, such as taking a
patient upstairs to the floor, or taking a pulse; they
would usually give me an answer, but would often add that I
needn't worry about that, "(I) would never have to do that
anyway."

Constraints on what tasks we did existed for all of
the clerical help. However, there was one ward clerk, Karen,
who was clearly an exception to this rule. When the ER got
overloaded she would take blood pressures or temperatures
and often asked the nurses if they needed any help. They
would occasionally suggest that she do this or that, and
after awhile she took it upon herself to help in such sit-
uations. Karen was a middle aged woman, very intelligent
and curious about medicine and also very sure of herself.
The manner in which she "took over" tasks which were outside

of her own job boundaries gave her an air of heroism; if only

35

because she stepped out of what was necessary for her to
do. It amazed me that she was able to do this and remain
in the good graces of the staff. After she worked there
for awhile the staff, doctors and nurses, would admiringly
Speak about Karen's dedication, remarking that she really
"helped out in a pinch." Thus, although constraints existed
for the clerical help (that all of the clerical help with
the exception of Karen stuck to the "rules of the Game" did
seem to indicate that there were constraints Operating),
it was possible for a persistent and curious person to go
beyond the boundaries established for her.

The work of orderlies, a group which consists wholy
of young men, was also well defined, but seemed to be some-
what less rigid than that of clerks. The orderlies cleaned
treatment rooms, situated patients in these rooms, performed
various errands ordered by the nurses and sometimes by the
doctor, and did "heavy_work" (although it seemed that there
were very few times when I actually saw them doing work
which was unusually heavy, this rationale was used by staff
in the ER when I once asked why they didn't hire women as
orderlies). Orderlies were also reSponsible for writing
descriptions of ailments on the patiaents' charts and for
taking blood pressure, pulse rate, and temperature of all
patients who were to be treated. They cleaned patients
also, that is, they cleaned wounds or lacerations to enable

the doctor to observe the injury more clearly.

36

Most orderlies were college students who worked
part time in the ER; and many of them were considering
going to medical school or were pre-med students who
were using”m1s work eXperience to "get their feet wet."
A few of the pre-med students occasionally complained
that they were unable to perform some of the tasks which
nurses or even doctors did; however it was not unusual
for these young men to initiate conversations with the
doctor on duty about how he dealt with this or that kind
of illness, or sometimes they would converse about med—
ical school admissions or classes. This kind of con-
versation rarely, if ever, went on between nurses and
doctors, at least on such a casual level.39

Although the nursing staff consisted of RNs and LPNs,
there seemd to be little observable difference in the
actual tasks which they performed?0 Both prepared pro—
cedures and techniques which were ordered by the doctor
and both assisted him in treating the patient. Nurses
sometimes questioned patients about their problem in
more detail than either the admitting clerk or orderly,
and usually they reported the patient's case to the doc-
tor. Nurses also accompanied the doctor into the treat~
ment room when he examined patients, and theyzssisted
the patient in getting prepared or undressed for the ex-
amination.

The sc0pe of responsibility and the ability to give
orders to other nurses does differentiate the RNs some-

what from the LPNs. The only male RN who works in the

37

ER once remarked that,

"the RN on the shift should know 'what' is in

every room at all times and should know what

is happening with that patient no matter what

it is."

This seems to imply that there is some supervisory work
involved in being an RN. This was further illustrated
in a doctor's remark about RNs who work at night:

"The RN on this shift has really got to be on

the ball; she's got to run the whole show down

here at night; it's a big job."

When there is an LPN working on this shift with an RN,
she can help the RN perform some of the jobs; however
there are tasks which only registered nurses can do, such
as signing charts, diSpensing medications and doing all
of the nursing paperwork.

Often RNs must do the more delicate or touchy jobs
in the ER. One of these jobs has to do with calling rel-
atives or friends of a person who has beenlrought to the
ER in critical condition. The RN usually will tell them
that their relative has been brought in for some reason
and that it would be good for them to come in. She usually
states that'Mey are "very ill," or were "injured pretty
bad" in some accident, if they are very bad; or if they
aren't critical, she will say that they are ”shaken up a
little bit," or they had a "little problem'with some ail-
ment. She won't give details if pressed but will contin-
ue to insist that they "come down to the emergency room"

and find out the patient's condition here. This is not

a comfortable job and often nurses hesitate before making

38

the call, or remark that they dislike the job or feel
sorry for the person being called. In this sense they
are aware of being "bearers of bad news."

Once the family or friends of the patient arrives,
it is the doctor who is responsible for giving details
about the patients condition, although the RNs usually
tell the doctor that the family has arrived. Upon ar—
riving in the emergency room, the family of the critically
ill person announces who they are (relative or friend of
"so and so" who was brought here with "some ailment"),
and the admitting clerk announces to the RN that "Mr or Ms
'so and so's relative is here." This is a signal for
the nurse to tell the doctor that the family is here,
and she will then direct the family immediately back
to wherever the doctor is. This involves bearing "bad
news" to the doctor, since it is a situation in which
he has to perform a particularly touch kind of job.

Another job which is delegated to the RN on the
shift is calling the doctor to see a patient if he is
in "his room." During slow times on a shift the doctor
on duty will usually sleep or read in a room reserved
for the staff doctors; when a patient comes in, eSpecially
one who is complaining of a relatively minor problem,
the staff will all conSpire to drag out the time it takes
to get the initial information from the patient and then
they will often laugh about the RN on duty having to call
the doctor. Often she tries to pawn off the job onto

someone else, knowing full well that this is ultimately

39

her reSponsibility. In part this has something to

do with the fact that particular patients are seen in

a bad light by the nurses. If they arrive in a slow period
after the physician has gone off to sleep, the nurses see
them as indirectly reSponsible for "making them call the
doctor." Since nurses rarely initiate encounters of any
sort between themselves and the doctor, and this is one

of the few times when they have to, nurses consider this
job to be an uncomfortable one.

I think that the point can be made that the initiation
of encounters relates to the hierarchical structure or
organization of staff members in the emergency room?1 Not
only the nurses, but also the clerks rarely initiated
conversation with the doctors. I always felt uncomfort-
able Speaking to any of the doctors or having to ask them
any questions; instead if I had to know information about
a patient, for example whether he would be admitted to
a medical or a surgical floor, or if he needed isolation
or not, I would ask anyone -- nurses, ward clerk, or
orderly —- before I would bring myself to ask the doctor
on duty. My feelings were reinforced by other staff mem-
bers, for if I asked a nurse whether my question Should be
asked of the doctor, She would respond that I should tell
him later, or she would try to find out what I wanted to
know in some other way. It was often obvious that the
nurses felt no more comfortable than I did with the doc-

tors. On the other hand, whenever I had to ask questions

40

about a patient or if there was room in the back,
or if I Should "send someone back," I also felt ill
at ease about asking a nurse. As an admitting clerk I
felt more comfortable asking other clerks or the order-
ly the same question.

The role of the doctors in me emergency room con-
sists of seeing the patient, treating him, and order-
ing other staff members to perform tasks which would aid
him in treating or diagnosing the patient and his problem.
After everyone has prepared the patient for the examination
by the doctor, and have obtained all relevant information,
the doctor checks the patient, announces what tests are
apprOpriate, or what should be done for the patient. All
of the doctors who work there phrase these orders very
concisely and upon announcing the orders leave immediately
to carry on with their work, i.e., signing charts, seeing
other patients, or returning to their room. There is a
distance maintained, and the doctor seldom does anything
outside of his narrowly defined role to aid any of the
other staff in accomplishing their tasks. It seems in
fact that the doctors are the most constrained inierms
of where they place the limits of their work; either they
are unwilling or unable to step outside of the jobs they
are supposed to perform.

This particular way of organizing work is often refer-
red to even by doctors, as a "team effort." However for
the patient, the process of being taken care of here is

much more like an assembly line. Patients often complain

CV”

buy

“AV.

(.7
O ’2

"5

 

r}-

41

about all of the various staff peOple asking them dif—
ferent questions; and also complain that any one staff
member rarely knew about anything that the others were
doing. Rather than a team, the roles of the various types
of workers were rigidly ordered in a hierarchy where orders
were given from the tOp down. It is true that in an emer-
gency situation the roles intertwined and enmeshed in such
a way that the workings of all staff members appeared to
resemble a "team effort," but the word "team" implies an
equalitarian organization of work; which even in an emer-
gency was not present.

Thus the SCOpe of care which any staff member can
participate in is narrowly defined by what tasks are
apprOpriate for that type of worker. The kind of contact
with the patient is limited, and rarely, unless the patient
is a "regular," do staff peOple ever discover the results
of their efforts. The goal is "to get patients in and out"
as quickly as possible, and all staff are evaluated in

terms of how well they carry out this goal.

42

Language and Meaning in the Emergency Room

 

If the new nurse finds she is only invovled in a
very narrow SCOpe of patient care, she will also learn
that patients who come into me emergency room are no
longer the "peOple who need her help," but rather if
they are patients with routine problems, they are inter-
ruptions of her work, and if they are "emergencies,"
they might turn out to be "eSpecially interesting cases."
Crises come within the realm of the eXpected and the
routine, and the peOple who come here for help become
"patients" who are defined in terms of their medical
problem and are labelled as "OBS," or "kidney stones;"
or in terms of the kind of work which they require the
staff to perform, such as "X-rays," or "admissions."

The patient's own understanding of his problem is inter—
preted and categorized by the staff; lay understanding

is transformed into the categories of insiders in the
emergency room. The process is not peculiar to ER med-
icine, however, nor to the medical profession in general;
rather in every occupation there is a special language

or taxonomic system which enables its members to deal with
day-to-day events and clients. Cab drivers, janitors, Shoe
salesmen, lawyers, social workers all have clients whom
they denigrate or praise for one reason or another, and
usually these reasons have to do with the work which the

clients require them to do.42

43

To work in the emergency room does rquire one to
learn a new language. It is important to place people in-
to categories of health and illness which can be used by
the staff to order their activity; on the other hand, the
categories of the "patient" tend to act back upon them to
define patients as "problems," rather than as peOple who
have problems. For example on one occasion during a
telephone conversation with a nurse on one of the floors
it became apparent how prevalent the "peOple as problem"
orientation was:

"hello, this is admitting. I have a person down

here who has a kidney stone. He is 25 and prefers

to have a double room; what have you got up there?"

"Just a minute, this is the aide; I'll get the
RN on the phone for you."

(in the background I hear: "ER'S got a kidney stone;
got any doubles?")

"Hello, this is the RN; you got a kidney stone, ha?

Well, put him in 32, one; ther's a surgery in there
too."

Not only is it important to know the language, but
it is important to know how the nature of work transforms
the lay categories of illness into medical categories;
and how the application of the categories is influenced
by social evaluations of the patient.

Whenever a person presents himself for care in the
emergency room, he is Screened by the staff on the basis
of a number of criteria. Although the medical nature of
the problem he presents is the primary element in the
staff's evaluation, there are other elements which weight

heavily. For example the patient's age, income, race or

F

44

lifestyle all feed into a total picture of the patient
and affect the way in which his problem is considered

by the staff. The successive interpretations of the pa-
tient's problem, which transforms a vague symptom into

a specific diagnosis, forms a process beginning with the
admitting clerk and ending with the doctors' interpreta—
tion of lab tests or K-rays. A Specific example of a
patient who has a vague symptom will illustrate how the
patient's understanding of his problem is re-interpreted
by the staff:

One evening while waiting for the admitting clerk
from the afternoon Shift to finish working. I heard
and observed her speaking with a patient who was black,
young, and dressed rather poorly. He was claiming that
he had a pain "down here." The admitting clerk asked
him,

"Where, 'down there?'"
and the patient,

"Down here, in my privates."
Because this statement wouldn't be easily understood
bV'me staff as it was stated, the aadmitting clerk
started to probe for some condition which she mi 2ht
write on the chr rt The statement should fit into
a ca te2ory which would be "reasonable to understand by
the staff." For Joda, the admitting clerk, this state-
ment was taken to mean that this patient who was black,
male, and on welfare, probably had VD.

"Do you think you have VD?"

"No. I just can't go to the bathroom, ya know what
I me? n?"

"Oh,‘men you're having trouble urinating? Okay,
can you get a urine sample?"

"I told you I can't go. How am I supposed to do tha t?"

"Well. why don't you have a seat then, and the doctor
will have a look at you in a minute."
On the 'chart Joda wrote, "difficulty urinating; pos-
sible VD."

When the nurse came to pick up the chart, she
read the chart and asked Joda if She had gotten a urine
sample from "this one." Joda responded that he wasn't
sure. but that She though that 'this one' as VD, and
didn't want to get a sample.

"Ye h he's the one over there (and She coyly pointed
to the ma who was now Sitting on a chair in the
waiting room.)

45

He said he had a "pain down 'you know where.'"

The nurse looked "over there" and muttered:

"Oh, God, he probably does have it. I guess

we'll have a look at him,"

and Screwed her face into a disgusted look.(Fieldnotes)

AS one can see from this exchange, although the
admitting clerk is responsible for getting from the
patient a statement of his problem which can be written
on the chart, if this apprOpriate definition is not
forthcoming, She can take it upon herself to construct a
problem which matches her own eXpectations and evaluations
of such a patient. An interesting ending to this story
was that the man had a urinary tract infection, not VD;
that other men, usually white, with this problem are not
suSpected of having VD indicates that diagnoses, at least
on this level, are affected by contingencies other than
ones which are purely medical?3

The categories of patient problems which are formed
by the admitting clerk are used to indicate to the staff
what kind of work is coming in, so that they can judge
how quickly to work, and know what sort of work and pa-
tients they will have to deal with. For example, if a
woman comes into the emergency room and has an obvious
bulge, and seems uncomfortable or if She is with someone
who is carrying a suitcase, I ask whether she is in
labor; if She replies that she is (which is usually the
case given these clues), I announce to any staff in the

nurses station behind me that there is an "OB" here

(obstetric patient, or a woman who is about to have a

46

baby.) This announcement carries with it a number of
prescriptions or rules about what certain members of

the staff Should do. The orderly has to step whatever
he is doing, and bring this woman to the labor and de-
livery ward of the hospital. The admitting clerk has to
obtain information about her husband or family, and fill
out Special forms for obstetric patients. The nurses

in this case have nothing to do Since the woman will be
going directly up to labor and delivery; and they usually
breathe a Sigh of relief that the patient turned out to
be someone with whom they didn't have to deal.

If an old man comes into the ER holding his chest
however, and announces that he has "bad pains in (his)
chest," the nurses as well as everyone else mobilizes
quickly to get the man back into a room and "hooked" up to
a heart machine. The announcement of chest pain accom-
panied by the presence of an old man, carries with it
rules for the nurses to get room #4 ready (the room for
critically ill or injured patients), and to call the
doctor out of his room if he isn't already present, and
to set up procedures to facilitate the man's breathing
and to reduce the pain. The ward clerk will call "cardio"
on the phone, and the orderly will make sure that every—
thing in four is clean and organized, and he will move out
any other patient who is well enough to be placed in anoth-
er room. To the staff this announcement carries warnings

of a "real emergency," and if there have been a lot of

47

other emergencies on the Shift, or even if there have been
many patients who have come in, this man means that the
staff will have to keep working and keeping up the pace
for another stretch of time. If the staff has been doing
little up until this time, they will usually have to break
up a conversation or forego the cup of coffee they were
about to have in order to care for this patient.

On the other hand if a young woman walks into the
ER announcing that she has "chest pains," she isn't consi-
dered to be a possible heart attack victim, but rather She
will be considered to be a "routine case." She is told
to have a seat, and is called to be treated when the order—
ly gets around to it or when the staff finishes the last
gulp of coffee. The nurses say that this is another per-
son who "Should go back to bed" (who probably has a minor
ailment), and take their time helping the woman get ready
for the doctors examination.

Thus in order to understand how patients are treated,
or to get an idea of how interpretations of illness are
made, it is important to examine how work is organized;
the eXpectations which deve10p from treating patients
with Similar problems repeatedly gives rise to particular
interpretations which serve as guides to the staff to help
them determine the pace at which they work, and the jobs
which they perform. To look only at individual staff
members and how they relate to patients ignores the con-
tingencies at work in the emergency room which defines

for staff a particular kind of reality.

ReSponses of the Nursing Staff Towards Work

 

I have up until this point described the emergency
room as a place characterized by unpredictability, by
extremeséof emergency and routine, overload and boredom.
The work which peOple do here tends to be narrowly de-
fined and job-specific; and as a result, the care of the
patient tends to be segmented. Patients are labelled
in terms of medical and social characteristics and in
terms of the jobs which staff must perform for them. The
crises which on one side of the counter might mean the
reality and tragedy of life-or-death, on this side of the
counter are part of a routine which workers perform daily.
If this is an adequate pictur of the emergency room, it
seems logical to examine how the members of this organ-
ization, and in particular how the nurses, reSpond to
the organization of work, and how they define themselves
with respect to other staff members, and with reSpect
to the patients with whom they must deal everyday. Later
I will show how the nurses who are involved in creating
a professional chapter of emergency room nurses differ-
in their reSponses.

In the previous section of this paper which deals
with the nature of "emergencies," I mentioned that one
evening Leanne, one of the ENS, was complaining about
how dull the emergency room had seemed to her that night.

After this comment I began to wonder what expectations she

48

49

had brought to this job, how other nurses felt about
the actual conditions of work, and how this "fit" with
their prior eXpectations of an emergency room nursing
job. When I asked any one of the nurses about what they
expected this place to be like, they seemed to have a
difficult time answering; however, they were easily able
to state that the reality of the day—to-day work was
not "what they expected it would be." At the same time
these peOple were convinced that this was a better job
than working "on the floor," and that it could even be
better "if it wasn‘t for all the 'crap' that comes in
(i.e., routine cases.) In general, nurses characterized
the emergency room as a desirable place to work, although
in the day-to—day milieu of the ER, there predominated
a cynical attitude and frequent complaints about the
patients and the work which they brought in.

One day when speaking to Mrs. Lange, the ER nursing
supervisor who worked on the day shift (7am—3pm), I
asked about nursing in the emergency room, particularly if
the nurses who worked here had Special training and
whether this was considered a good place to work. She
reSponded that the nurses acquired muCh of their training
on the job:

"it really goes fast down here sometimes, and you

couldn't really learn ER nursing unless you get

your feet wet right here."
She continued to tell me that the nurses "from the floors"
were "dying to work here; it's exciting here and things

move fast."

50

Ron, one of the ENS on the afternoon shift (3pm-llpm),
remarked:

"we see an awful lot down here; it's better

experience and you don't have to deal with

peOple who ay around for months like they do

upstairs."

Jean, another RN who works days added that nursing here
was a lot better than working upstairs:

"this place is a lot better than working on the

floor; down here we don't have to change beds or

take care of patients who hang around for months.

Patients who come here come in and leave fast."

I discovered then that at least to the ER staff,
nursing in the ER was preferred to nursing on the floor,
particularly because a nurse wouldn't have to be involved
in long-term patient care. Rather patients are "processed
quickly and leave; and nursing is restricted to performing
Specific tasks and procedures which vary by the medical
category of patients, and the seriousness of their condi-
tion. Contact with the patient is restricted to a quick
visit into the room Where the nurse perfroms the task she
has been ordered to do before she hurries on to the next
room to carry out more orders. Because the goal of the
emergency room is to get patients "in and out fast," Speed
and efficiency is highly valued in an emergency room nurse.
How well they set up procedures and diSpense medications
or just get peOple out, is a source of competition among
some nurses; and since the Sc0pe of care revolves around

such tasks, evaluations of competence are centered around

how well they are performed.

51

Although most ER nurses concur that emergency room
nursing is superior to "floor" nursing, there is another
thread of concern which runs through their comments: they
would like more contact with patients. I have heard RNS
several times Speak nostalgically about student days and
their involvement with the peOple who served as their "case
studies." Jane, a particularly good nurse judged by the
standards which existed in the ER, once had a conversation
with a nursing student who worked part time as a ward clerk
in the ER. Jane started talking about how she enjoyed get-
ting to know the woman who was the subject for her case
study.

"she was such a nice lady; I went to see her every-

day; we had to see them all the time to keep obser-

vations on their progress, and I really got to know

her, and She got to like me, too. Not long ago I

found out that she died; and I was really sad. That

was a really good experience though.

Ron, the male RN, would also occasionally Speak of
how he like to spend time talking to the kids who came into
the ER; he was excited one day when I told him that a little
girl had asked for him the previous day when he wasn't
working. He reSponded that he really enjoyed "little kids,"
and

"it's a really good feeling to let them know you're

on their Side when they come here feeling sick, and

know they are going b get a shot."

The consequence of "emergency care" includes the fact
that not only does one try to hurry patients along through

the process, but also that one rarely sees them again to

find out how they are doing or if they are recuperating.

52

Instead, patients are referred to private physicians for
follow—up. Thus nurses seldom find out if their care
helped a patient, nor do they ever get the satisfaction
of seeing a patient who has been helped in the ER. Al-
though the nurses never Spoke Specifically about this, it
was instructive to hear them inquiring about patients
who had been admitted to the hospital after being treated
in the ER. Often they would call upstairs to find out how
a particular patient was progressing; and news of different
patients who came through the emergency room was always
welcomed. Thus, nursing was considered to be a better
job down in the ER because there were no long term patients,
however it seemed that nurses were not totally satisfied
with the brief, assembly—line style of caring for patients.
Nurses believe that the emergency room should exist
to treat emergency cases only, but this definition of
emergency nursing is at odds with the reality of work which
involves many routine cases. Routine cases are disliked,
and the work which they create is seen as "inapprOpriate,"
or undesireable. When a patient comes into the emergency
room with a routine complaint, nurses often make caustic
remarks about them. One night when Jane was working. I heard
her comment how she couldn't believe "the guts that peOple
had for coming here with a backache that they had for three
months!" On another occasion when the ER had been particu-
larly Slow, a man came in complaining of a stomach ache;

Jane remarked,

53

"God, I just can't stand this kind of stuff; what

do they think we're here for anyway? Babysitting?!"
Unless a patient enters the emergency room in a dramatic
way, by ambulance, screeching ca , carried byzfiiends or
family, or holding a bleeding wound, he will be considered
"not too serious." In fact most patients need to be "proven
ill" for staff members to think of them as using the ER
apprOpriately. One evening a man came in with his brother
and complained of trouble urinating. The waiting room was
filled with peOple and the treatment rooms were all taken.
The man was in much pain and his brother was persistent
about wanting him to be seen immediately. When I related
the problem to the nurse, She told me to tell him that every-
one there had some problem and to just wait until there's
room:

"These peOple think that they're so Sick for the
littlest thing..."

As it turned out, the man did have a problem which was
severe enough to warrant his admission to the hospital.
When the doctor was writing out the admission order, the
same nurse looked over his Shoulder and said:

"This one's really getting admitted? I'm surprised
that he was that Sick!"

On another morning an old woman entered the emergency mom
and whiSpered to me that she felt a little dizzy. I wrote
down "dizzy" on the chart and gave it to one of the nurses.
She read it and said,

"Oh come on; why does this stuff come just when
we're ready to go home?"

54

When the orderly returned from taking the woman's pulse
he exclaimed that her pulse rate was 180/160, a very high
rate, and reported that she had been nauseated all morning
(a symptom of a heart failure.) After the doctor looked
at her he decided that She had had a heart attack and she
was admitted immediately, to the surprise of everyone.
Although the staff are suspicious of many of the peOple who
come in with serious complaints, it is true that a large
number of people do seek help in the ER for minor, routine
complaints; in a sense the cynicism is a protection from
the numbers of patients the staff must see without being
able to screen them or turn them away?’4

Often nurses complained about doing certain kinds
of work; for the most part this disfavored work was assoc-
iated not only with routine cases, which some felt wasted
the time of "professional staff," but also with categories
of patients with particular social characteristics. Old
peOple, black peOple, peOple on welfare, dirty peOple,
drunks, overdoses, psychiatric patients, attemted suicides
or patients with gynecological problems, or public diseases
such as VD, or peOple who arrived in ambulances but were
not eSpecially "critical," were disfavored and disliked
by the staff. In an article on emergency services (Roth,
1972) Roth states that when Service groups don't have con-
trol over their clientele they will demand compliance of
groups which are particularly disfavored, rather than trying
to socialize them to "behave" in the way they see fit. It

was frequently the peOple in these categories who were

55

shoved around, made to wait longer than other patients, and
were Spoken of rudely by staff members.

Some of the nurses who worked in the emergency room
were intent on doing work which was "clean." Patients often
require nurses to perform the "dirty work" which they were
happy to leave on the floors. Drunks require them to in-
duce vomiting, as do overdoses; old peOple often need to
be cleaned up or need bed pans; dirty peOple often need to
be undressed, thus nurses have to smell them; and uncritical
ambulance patients require nurses to run out to meet them,
for no "real" reason. None of the emergency room staff
liked doing any of these things, although some of the nursing
staff saw this work as a "drain" on their "professional time."
These nurses would be particularly "put out" by such patient
demands on their time and person.' Who these nurses »are and
why they are particularly concerned about their professional

status will be dealt with in the following pages.

Professionalism and Emergency Room Nurses

 

The responses of nurses toward their work in the
emergency room is shaped to a large extent by the organ-
ization of work they do, and by the contingencies of crisis
and boredom which exist side by side in this setting. How-
ever to avoid presenting an image of the nurses as an un—
differentiated group, all reSponding similarly to the events
in the emergency room, it is important for us to investigate
how various nurses relate to the issue of professionaliza-
tion, and how this fits with their eXperience of work in
the emergency room. If we are to examine how rank and file
nurses respond to the drive for professionalization, then it
is important to see who is talking about it, in what way,
and how their concern with professionalization differentiates
their behavior on the job from other nurses who aren't as
concerned about the issue. Later there will be a discussion
of the factors existing within the emergency room which makes
the issue of professionalization so appealing to this parti-
cular group of nurses.

One group of nurses who work in the emergency room of
Community hosnital are involved in setting up a county-wide
chapter of emergency room nurses.45These nurses have famil-
iarized themselves with the charter of the national group
of emergency nurses, and are interested in stimulating some
concern for this among nurses in the area. They have parti-

cipated in setting up meetings with nurses from other

\T!
O\

57

hOSpitals, and they have attended the national convention
of emergency room nurses. Ron, one of these nurses, has
been particularly concerned that nurses take an interest in
learning more about emergency room care, and also that they
begin to consider themselves as "professionals," and as
peOple who consider nursing as not just a job, but rather
as a areer. Ron and other nurses have also thought that
the emergency room nurses should gain more autonomy from
physicians, and from the emergency room supervisor, Mrs.
Lange. One plan which they see as feasible for the future
is to form an independent corporation of nurses, which
would certify its own members. Doctors who run the emer—
gency rooms (in a similar way to the anner it is run at
Community) would hire nurses from this group on a contract
at a certain set salary. The nurses who were hired would
be placed on a ninety-day trial period; those who were not
"up to the standards of efficiency set by the board," would
not be approved, instead only nurses who meet the standards
would be allowed to stay. This board would consist of cer-
tified nurses from the emergency room, and also the doctors

there;46

all would have equal say about whether the "trainee"
would be certified. Both RNS and LPNs would be approved in
this way, although LPNs would be judged on different criteria.
In this way nurses (RNS) who work in the emergency room

would have power to certify, hire and fire, other nurses

who work in the ER; in addition, the role of supervisor

would be changed so that a board of nurses would have power

to make decisions along with the physicians. Although their

\n
00

plans are by no means complete, it is important that their
vision of the future includes more autonomy and power for
themselves. In this way, being "professional" for these
rank and file nurses parallels the concern with autonomy
which characterizes the leaders of the field.

The conflicts which frequently arise between Mrs.

Lange, the ER supervisor, and this particular group of nur-
ses is an indicator of their dissatisfaction with the de-
gree of autonomy which they now hold. They complain that the
supervisor should have more involvement with direct patient
care, and less involvement with paperwork; they are also
dissatisfied with the amount of authority she has in grant-
ing hours, allowing time for professional meetings, and in
general her authority over the distribution of work among the
nurses. Although hrs. Lange claims interest in an emergency
room nurses association, it seems that the establishment of
such an association would threaten her position.

The nurses who are involved in creating these plans are
primarily RNS, trained both as technical RNS and "profession—
al" baccaulareate RNS.47 They are young, under 35; and are
for the most part single, and without families. Most of this
group has worked for only a few years, although two of these

48

nurses have been working longer. These peOple doxmrk full

time, and seem to be concerned with nursing as a full time

K_.

career. On the job, these nurses seem to be particularly
competitive, and udge one another according to criteria of
efficient work. Ron once mentioned that he really liked
working on the afternoon shift (which was diSprOportionately

staffed by these young, single nurses), "when even LPNs

VLJV

fight each other to set up IVS." He added that this was
not what it was like on the day shift, which was staffed by
older married women.

"nurses sit around drinking coffee all day and
talk about their kids and their home furnishings."

The younger, career-oriented nurses, would criticize these
nurses for not living up to standards of efficiency and Speed.
Allyson, a nurse who had been away from work for a few years
to stay home with her children, was criticized behind her
back for having a difficult time "getting things going and
getting medications out." If a nurse doesn't fulfill the
norm, "they don't belong here," according to several of these
nurses.

Not only are these nurses competitive and eager to learn
and perform new procedures, but they also tend to be defen—
sive about the use of their "professional time." They are
more likely to complain about their time being wasted by
"inapprOpriate patients," and they are less likely to take
over the work of staff members below them in the emergency
room hierarchy. One of these nursesxould complain repetitive—
ly about having to make calls forgatients if the ward clerk
wasn't working and able to make the calls herself. Although
reSponses to patients are affected by how a particular nurse
views the use of her time, in general the organization of
work and the contingencies shaping the work in the emergency
room have a great deal to do with how she will view patients.
For all of the nurses there are apprOpriate and inapprOpriate

patients, depending on their use of the emergency room; the

60

difference lies in the fact that some nurses care more about
this than others. This is eSpecially true for His who have
been trained to eXpect that their time will be used meaning—
fully; this contrasts with the training which LPNs have
which prepares them for the "dirty work" which needs to be
done.

Those nurses who are less concerned with nursing as

93
o

areer, or professionalization of the emergency room nur-
ses, are either LPNs who work full or part time, or they

are older women who have been away from nursing for awhile,
or who work only part time in the emergency room. On the
job these women spend a lot of time talking about Children
or the home, while the nurses who are more concerned with
their prof ssional role often talk about techniques, or
medical issues, or the like. The "non-professional" will
often comment that they are working for extras, and in order
to help out their husbands. One older nurse remarked once
that she couldn't wait until her husband retired so that she
could quit working also. These nurses rarely speak of the
emergency room as a particularly different place; rather
many of them consider it simply a place to work. The im-
portance of the home and family to ma y of these women helps
eXplain their attitude toward work in the emergency room;
rarely do these nurses eXpress a desire to work more, or to
attend conferences or meetings. Free time is spent at home,
and frequently these nurses will bargain with Mrs. Lange to

decrease their hours.

61

Thus the group of nurses who were younger and most
recently graduated from nursing school, seemed to account
for themselves as professionals more often and more straight-
forwardly than nurses who had been out longer or who were
older. Not only did this group support the idea of a pro-
fessional association, but they also displayed a very par-
ticular way of behaving toward patients and their work
which was not present in the other nurses. Although all
of the staff had ideas about what kind of work was appro-
priate or inapprOpriate, nurses who considered themselves
to be professionals were particularly aware of how their
time was Spent, and would seem to be more disturbed by pa-
tients who represented "dirty work." Their conscientious
use of time, their orientation toward work as career, and
their awareness of their own lack of autonomy reflected a
concern about who they were. To these nurses being profes—
sional meant that one was competent, efficient, and also

that one was serious about work.

Summarv
————_—&-

I have attempted to present a pictunaof how nurses
in a particular setting account for themselves as profes—
sionals. and also I have:ttempted to show actors in the

setting which would allow professionalism to be appealin

m

to some of he nurses who work Within this setting. In the
emergency room milieu, nurses are confronted with work
which is narrowly defined, contstraining, and segmented.
Contact with patients is brief, and often is separated by
long periods of inactivity, waiting for something to happen.
Much of the work is routine and most often nurses here do
not deal with exciting cases, but rather with illness and
injury which is more likely b be seen in a doctors office
than in an emergency room. It seems that the way of ac-
counting for oneself as professional, is a way of deriving
some meaning from this particular type of work. The ex-
ample of professionalism among several of the hOSpital
workers, physicians and various paramedicals, offers a means
of eXpressing one's own importance in the face of such
segmented and constraining work.

The nurses in Community's emergency room are saying
something about who they are and what their work is all
about by stressing the importance of efficiency and compe-
tence and the saliency of their time. It seems most rea-
sonable to eXpect that the nurses involved in deriving

their identity from their work are also the peOple who

63

have no investment in family; thus the nurses who see
their work as having much importance are also the nurses
who are young, unmarried, or without children. It is
these nurses who can afford a commitment to nursing as
a career.

Thus the organization of work in the emergency
room, as well as an aura of concern with professionaliza-
tion of emergency room staff among physicians, contributes
to a consciousness of professionalism among the nurses
who work'mere. In addition, it is only particular nurses
who will be affected by these ”prediSposing" factors;
that is, young, unmarried, or childless nurses are most

likely to find the idea of professionalization appealing.

64

FOOTNOTES

 

lOften during various times on a shift, staff members

refer to the fact that they are "holding down the fort."

In part this feeling arises from the fact that the emer—
gency unit is a small one and has a rather small staff; and
the feeling that it is also isola. ted from the rest of

the hOSpital gives the staff the idea that it is a "forti-
fiable" unit.

2In the later part of the thesis "professiona lization"
and how it is discussed by the staff is spelled out more
clearly.

3Fred E. Katz, "Nurses," in Amitai Etzioni, The Semi-
Professions and Their Organization (New York: The Free
Press, 1969), pg. 73.

4Faye G. Abdellah, Irene L. Beland, Almeda Martin,

Ruth V. Mathesey, New Directions in Patient Centered
Nursing (New York, 1973771p. Pl. Discusses the need for
more descriptive studies on the professional nurse.
Elizabeth K. Porter, "What it Means to be a Professional
Nurse, " in AJN, August, 1953, pp 948— 50. Examines differ—
ences between "Professional nurses and technical- degree

nurses .

5Peter L. Berger and Thomas Luckmann, The Social Construc-
tion of Reality (New York, 1967),Doubleday, p.47—128.

6This particular work system model is Spreading however.

For example in law, professionals in the field are trying
to develOp para-legal occupations which would be organized
around the central occupation of law. However, medicine
has gone furthest in this direction; see Barrie Thorne's
discussion of this type of organization in a report pre-
pared for the Carnegie Commission on Higher Education;
Education for the Professions of Medicine, Law, Theology,
and Social Welfare, pp. 75-80, and 111-120.

7Elliot Freidson, "Paramedical Professions," in Internation-
al EncyCIOpedia of Social Sciences, David L. Sills, ed..
Vol 10, pp. 114— 120.

8Robert Kinsinger, "Training Health Service Workers: the

Critical Challenge, " in Proceedings of the Department of

Labor, HEW Conference on Job DevelOpment and Training for
Workers in Health Services, washington, DC., Feb. I4— 17,

1966, p. 27.

9The difference between technical training and professional
programs lie in the fact that the former are not considered
to be fully "professional." What is interesting is that
the technical programs are becoming more and more pOpular;
especially the programs offered in 2—year colleges (assoc-
iate degree programs.) These have increased from only

 

 

 

 

 

 

65

three programs in 1965, to 129 in 1971. (From Abdellah,
et.al., ibid),

10Everett C. Hughes, Men and Their Work, (Glencoe: The
Free Press, 1958).

11Rue Bucher, and Anselm Strauss, "Professions in Pro—
cess-" AJS, May 1961. In this article Bucher and Strauss
discuss the notion that every occupational group is
broken up into "segments"; that is groups within the
occupation which have particular interests and postures.
Within nursing, even the "rank and file" is not a totally
homogenous group. For example, LPNs and RNs might see
themselves at odds and represent two separate "segments"
within the rank and file.

12

 

 

Fred E. Katz, 0p.cit. p. 73

l3Increasingly there has been a concern for recruiting
men into the field. This would of course, raise the
status of the occupation, since occupations consisting
predominantly of women tend to have low status.

l4Women's role in the family has accounted for the high
turnover and attrition rate among nurses. The home,
traditionally the place where women were to get their
ultimate fulfillment, often wins the young neOphytes.
However, lest this become the total explanation, it is
important to remmber than increasingly large numbers of
women with children and families are working; and that
often this work accounts for a larger share of the family
income than just "extras."

I:
l’Everett C. Hughes, The Sociological Eye, Collected Papers
on WorkL,Selngand the Study of Society, (Glencoe; The
Free Press, 1971)

16R. Corwin, "Professional Employees: A Study of Conflict—
ing Nursing Roles," AJS, May 1961.

17Rose L. Coser, Life in the Ward (East Lansing: MSU, 1962);
Or Leonard Riessman and John Rohrer (eds.), Changing
Dilemmas in the Nursing Profession (New York; Putnam's,

1957)

18Hans O. Mauksch, "The Organizational Context of Nursing
Practice," in Fred Davis, The Nursing Profession, pp. 109-
137.

19ibid., p. 130
20The name of this hospital is fictitious

21"ER" will be used throughout this thesis to refer to
"emergency room."

 

 

 

 

 

From an article in Time Magazine, August, 1973.

66

23See Hans O. Mauksch, "The Organizational Context of
Nursing Practice," in Fred Davis, The Nursing Profession,
p. 120, for a discussion of the effects which the tran-
sient hospita 1 physician has on the organization of
nursing.

24Specifica ally, there are percentages which can give the
reader an idea of the composition of each shift; During
the time Ivorked in the ER there was some turnover on
both the afternoon and evening shifts. However, the

day shift remained the same during this time: there were
two full time RNs and one LPN; all three were married,
older than 35 and had children in school. The afternoon
shift was worked by two RNs and one LPN, also, who were
under 30, the ENS were single, and the LPN was married.
The night shift consisted of two RNs, both who were
single and under 30. There were part time LPNs who work-
ed this shift occassionally; they were over 35. and had
f amilies.

25"Cardio" technician refers to Inhalation Therapists. They
are a relatively new paramedical occuaption, and assist
peOple who are having difficulty breathing, or who are
suffering heart failure, etc.

26The night shift did differ from the other shifts in

a few ways; the rigidity of relations among'Me staff seem-
ed to be quite a bit more relaxed at night. Once in a
while, the doctors would join the rest of the staff in
talking about "little league," or side business ventures
they were engaged in. The orderly was informally allow-
ed to leave the hospital to get pizza or donuts for the
group, and often big feasts were prepared in the emergency
nurses' station for eating during the night. There was

a sense of "holding down the fort" during the night; and
peOple would often comment about the additional respon-
sibility as a result of the lower numbers of staff peOple
who were working. For a discussion of how the night

staff in a hospital differ from the daytime staff, see an
unpublished paper by Jean Kozak, Michigan State University.

27By this I mean that I was one of a few who were not in-
volved in the medical world; even several of the ward
clerks were also either nursing students, or were in pre-
medicine programs. The orderlies as was mentioned before,
were often Dre-med students; and even the admitting clerks
were often nursing students.

28All of the names which are used throughout this paper
are fictitious.

29Although the nature of work in chronic care wards is not
dealt with in detail in this paper, there are several
available descriptions of such work; Rose Coser, Life On
the Word, (Ea st Lansing: Michigan State University), 1962;
Fred E. Ka tz, unpublished study of nurses in a 500 bed
hOSpital in a northeastern city, 1967; Fred Davis, Th§_
Nursing Profession.

 

 

67

30All of the quote tions used in this paper come from
fieldnotes taken on the job, January throub o*h September

1073.

31This is a condition not peculiar to this hospital, but
which is prevalent in all emergency centers across the
U.S. In 1970, 50 million visits to emergency rooms were
made, as compared to 15 million visits which were made
in 1955. Increasing numbers of peOple aren't able to
afford doctors' fees, and it is more and more difficult
to find doctors who accept new patients or who can care
for their regular patients. Hospital emergency rooms
have taken up some of this demand for medical care (Pa-
rade togaz1ne Detroit Free Press, February, 1973.)
Often I have asked patients to name their family doctor;
they will remark that they wouldn' t be here if they had
one; or that they had called their doctor and were told
that they couldn't be seen for a week or so. For patients
with headcolds or backaches, this is hardly a realistic
time period to wait.

32Everett C. Hughes, "Work and Self," in The Sociological
Eye. Collected Papers on Work. Self, and the Study of

Societ , (The Free Press, 1971).
33Hughes refers to the social psychology of work; how
peOple fit their work with their life, thus giving mean-

ing to work which glorifies it or at least makes it tol-
erable; ibidI p. 342—47.

34Hughes, ibidI Essay on "Mistakes at Work," pp. 316-25.

35This term was often used by admitting clerks to refer
to themselves in relation to other staff in the ER. On
one particular occasion I heard this being used when one
admit+ ing clerk was describing what she did to an E1 IT
trainee, an ambulance emergency trainee who did observ-
ingijn the ER.

36This idea can be compared to Hughes' idea about "protect-
ing professionals from their mistakes." In a sense the
clerks and orderlies serve as buffers between patients

and doctors; they keep doctors from being directly both-
ered, and keep pa tients from knowing "that the doctor
doesn' t know. "

37See D avid Sudnow, "Bad News," in The Social Organization
9f_Dying, (New Jersey, 1967), pp 112-252. Telling patients

cad news or facing and carrying on discourse with grief—
stricken peOple is a problem for members of an orga niza-
tion who have to carry on with business-as-usual.

38This was often a point of contention between myself and
the wt ff I wanted to set the patients in and out of

my area. and the staff wanted to be bothered as little

as possible. Once one of the RNs said that the mark of

a good admitting clerk was to be calm during these times

68

and keep putting off the patient.

390rderlies with further ambitions in medicine (e.g.,
pre-med students) are an exception to the general rule
that those lower in the medical hierarchy cannot move
up to another category. Being an orderlylas a sort of
vestige of apprenticeship; although actual advancement
requires formal schooling.

40The difference between RNs and LPNs are in training

and performance of some tasks. Historically LPNs e-
volved to take over functions which regular nurses per-
formed; RNs consider their training to be "professional;"
LPNs consider theirs to be "Technical." See Dorothy
Deming. The Practice 1 Nurse,(The Commonwealth Fund, New
York, 947; )and Gra ce 5. Fitch, The Role and Responsibil-
ities of the Practical Nurse, (New York; Nacmilla , 1969.)

1 . . m . .
4 Erv1n§ Goffman, Presentat1on of D€1f 1n Everyday Life,
(Ne cw'York; Doubleday, 1959), p.

42See Ray Gold, "The Chicago Flat Janitor" (unpublished
Naster's thee is, Department of Sociology, University of
Chicago, W0) Erving Goffman, ibid, for concepts of
frontstcse a.nd backsta.e; p. 106-140; Paul CresSy, The
Taxi-Dc nce NC 11 (Chiccgo: University of Chica=go Press,
1932; Lilliam F. 'uhyte, Nen a work, (Homewood, I11:
{ichard D. Irwin, Inc., 1961) pp. 125-135.

43There is an extensive literature on the social definitions
of illness and the problems of interpreting symptoms.

 

 

 

 

 

 

44Julius Roth, "Some Contingencies of the Nora 1 Evaluation
and Control of Clientele; The Case of the Hospital Emer-
gency Services, " in fiJS, Vol 77, No. 5, 1972. Much of
Roth‘s discussion of* control over clientele is relevant
for this discussion. That wt ff feel some need to "screen"
clients in a p19 .ce where they are forbidden to do so is

one way to understand i,hy pa atients a.re seen in such a

ba d light by those on the "inside."

45A National association of Emergency Room Nurses was
established in 1968; it is relatively young and has not
enjoyed wide-spread rosponse as of yet.

40It seems that although the nurses are seeking autonomy
from physicians . their plan does not exclude the possibil-
ity the t physicians still are able b wield some power.

47Two of the nurses promoting this professionalism have
tw -year technical RN degrees; three of them have
BA degrees

48One of the BA and one of'me technical RNs have worked
longer than five years. Although they are older and have
been around longer, they have full-time career ambitions.

APP END IX

 

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