Dangerous and Unprofessional Content: Anarchist Dreams for Alternate Nursing Futures

Abstract

Professionalized nursing and anarchism could not be more at odds. And yet, if nursing wishes to have a future in the precarious times in which we live and die, the discipline must take on the lessons that anarchism has on offer. Part love note to a problematic profession we love and hate, part fever dream of what could be, we set out to think about what nursing and care might look like after it all falls down, because it is all falling down. Drawing on alternate histories, alternate visions of nursing history, we imagine what nursing values would look like, embracing anarchist principles. We consider examples of community survival, mutual aid, and militant joy as strategies to achieve what nursing could be if nurses put an end to their cop shit, shrugging off their shroud of white cisheteropatriarchal femininity that manifests as professionalism and civility. We conclude with a call to action and a plan for skill-building because this can all be different.

1. Introduction

Anarchism is dangerously destabilizing for professionalized nursing. Anarchism’s rejection of hierarchies demands a rejection of professionalized nursing itself, given nursing’s ongoing entanglements with oppressive regimes of capitalism, managerialism, and professionalism. The circumscribed epistemological and ontological bounds of professionalized nursing as a care practice cannot survive the expansive generosity of anarchism. Many nurse leaders physically cringe at the word “anarchy”, classifying it as dangerous and unprofessional, immediately lamenting the imagined horrors: Chaos! “People would die”, nurse leaders say, clutching their pearls. As if people are not already dying, have not been dying. This reaction is a failure to identify the horrors produced by the violent order imposed by capitalist healthcare systems. But it does not have to be this way.

We are nurses whose hearts were broken by nursing in this healthcare system. Our tears nourished and cultivated a commitment to set out to do what we tried to in the first place: help people survive and leave the world a little better than we found it. Or at the very least, minimize the harm along the way. As the late-COVID-19 healthcare–industrial complex (HIC) gasps and wheezes through its dying breaths, nursing needs [r]evolution. In this paper, we set out to think about what nursing and care might look like after it all falls down, because it is all falling down. We invoke the image and ideas of nurse and anarchist Emma Goldman to imagine what nursing values would look like, embracing anarchist principles. We consider examples of community survival, mutual aid, and militant joy as strategies to achieve what nursing could be if nurses put an end to their cop shit, shrugging off their shroud of white cisheteropatriarchal femininity that manifests as professionalism and civility. We conclude with a call to action and a plan for skill-building because this can all be different.

2. Have We Ever Been Nurses

As we think through the unlikely pairing of nursing and anarchism, we start with a few words on nursing. Unlike many or most other things understood as universal, nursing is one of those things that most of us will experience in our lifetimes. For most reading this paper, that reality has likely already come to pass. Nursing is a relational care praxis that draws on art, care, science, and community to support wellbeing, health, and disease prevention, as well as care in illness [1,2]. This kind of care happens everywhere and is not limited to professionalized caregivers. Efforts to exercise proprietary claim to care—and exorcize those deemed unworthy to and of care—including nursing care, give rise to some of the most egregious and insidious structures that harm nurses and people who need care alike. The public imbues nursing with trust [3], an honor of dubious lineage that simultaneously confers pastoral power on nurses while enforcing docile maternal bodies.

In the history of nursing, the specter Florence Nightingale is regrettably the first image conjured to mind. Nightingale serves as sort of a golden spike, fixing the popular and professional imaginary of nursing in a rigid Victorian schema, articulated through such virtues of Christian femininity as obedience, sacrifice, modesty, order, cleanliness [4]. Nightingale, however, was not the first nurse or only nurse. Nursing care is not now and has never been proprietary to professionalized nursing. Well before Nightingale’s arrival on the scene, nurses were nursing, people were caring for one another. This begs the question, who does the synecdoche of Nightingale-as-nursing as shorthand for the discipline serve? As we think about nursing and about anarchism, it is worth contemplating the archism of professionalization.

Following the intervention of Martel in this issue, we understand archism as “a form of projection of authority, the assertion of a deep, ontological basis for power that is in fact based on nothing at all” [5]. For nursing, this is manifested and enforced through the image of Nightingale, a projection of a “mythic violence is the means by which that system sustains itself” [5], razor edges softened by romantic visions of care and entrustedness. Nursing is afforded one history, one image, one ontology—a singular trope on which our history and present balances, at the expense of all other possible pasts, all other stories of what nursing has been, could be [4]. This singular vision forecloses on alternate narratives while simultaneously stifling dissent, denying complicity, demanding obedience, enforcing white heteropatriarchy, establishing and reinforcing nursing’s place in the paternalist hospital family [6], and by turns mobilizing the Janus faces of archism to consolidate power and enforce discipline [7]. For an especially powerful treatment of how racial hierarchy is enforced in nursing leadership, see [8]. And as long as nurses cleave to this, refusing to recognize what is so clearly unfolding before them in the necropolitical economies of healthcare, we have to wonder what it means to nurse, to care [9].

3. Irreconcilable Praxes? Anarchism and Professionalized Nursing

• And the people in the houses
• All went to the university
• Where they were put in boxes
• And they came out all the same
Malvena Reynolds

In our collective experience as professional nurses living and working in nursing leadership spaces in the United States, we can confidently say that the specter of anarchism raises the hackles of many (most, even) of our compatriots. While clearly, we—an authorial “we”, which we will use throughout rather than a nursing “we”—think otherwise, we find thinking through those kneejerk reactions is useful. It seems that, though nursing frequently lacks the vocabulary to really speak to the issue, professionalized nursing recognizes the rejection of capitalist hierarchies and oppressions as a rejection of the nursing profession itself. Because it currently operates fully enclosed by the logics of late-stage capitalism in concordance with the carceral, economic, political, and pastoral logics that structure the healthcare–industrial complex (HIC), American nursing—organized nursing—is fundamentally at odds with the generative unruliness of anarchism’s epistemology [10]. This irreconcilability grows from professionalized nursing’s colonial roots; conjured into being as the managerial practice we know today by Nightingale, nursing as a discipline has been loath to loosen its grip on—or even directly engage with—the white cisheteropatriarchal phallogocentrism that structures its hegemony [4]. Nursing’s foundation of and continued adherence to the values of obedience, religiosity, white supremacy, imperialism, and capitalism allows nursing to derive its power from existing dominant power structures, which are squarely at odds with the ethos and praxis of anarchism.

Professionalized nursing is a total institution [11,12]. Without nurses’ continued compliance with the carceral logics of the neoliberal and racial capitalist order, healthcare—a powerful tool of oppression and control—would cease to function. In order for people to function effectively as handmaidens in the HIC, a totalizing transformation is necessary to convert them to nurses, nurses who function according to the metrics of healthcare productivity, quality, and compliance. This process begins in nursing school and continues throughout nurses’ careers with workplace orientations, professional development, organization membership, career advancement… The mortification of self that ensues assures that nurses are docile bodies, habituating nurses to capitalist, colonizing, and carceral practices. Nurses are made, ready to be both governed and to govern. Control over nurse identity and the power to define who nurses are and what nurses do are central to the intersection of power, agency, governance, and oppression [11,12].

Pursuant to professionalized nursing’s romance with capitalist healthcare schemes in the United States, surveillant metrics are employed to “measure” the value, success, and usefulness of nurses and thus nursing practice (for more on this, see “Getting Ours? ‘Girlbossing’ and the Ethics of Nurse Reimbursement Models”, a forthcoming paper currently under review). These metrics, however, are poor proxies for nursing value or really anything of meaning at all. There is no capitalist, institutional, or state ruler by which the complexity and realities of the posthuman experience of nursing can be measured, valued, parceled. Neoliberal managerial interventions like LEAN Six Sigma methodologies in hospitals produce linear graphs and measurable metrics. Leapfrog Hospital Safety Grades, ranking hospital safety, and Center for Medicare and Medicaid Services (CMS) Gold Star Ratings tell us, in elementary pictographs, which institutions merit the most stickers on the sticker chart. But what do these really tell us about nursing care? Panoptic surveillance technologies track footsteps and turnaround times, marching out reports at a reliable cadence while electronic health records (EHR) convert whole people into mineable fields of data, an endless supply of bullshit for the bullshit machine. All of this extraneous and manufactured “evidence” of nursing’s value redirects the attention of nursing to activities other than care while simultaneously justifying the relentless administrative bloat of the HIC as the managerial scaffolding required to support such efforts balloons.

But it does not have to stay this way. Nursing and care can choose different paths, uphold different values, center those who are most harmed. As historians Kylie Smith and Thomas Foth note in their call to anarchism for nursing, “nursing is implicated in hetero-patriarchal, neoliberal and colonizing systems that stifle nursing’s emancipatory potential” [13] (p. 16). And nursing does have potential for the project of liberation—if nurses choose it. As we explore resistance, we highlight the existential threat to nursing and the folks in our care if we do not, collectively and through direct acts of resistance, potentiate the abolition of the carceral state and invest “in the liberation of people and the power of communities” [14] (p. 15).

4. Anarchist Visions for Nursing or Why Nurses Should Be Anarchist

The incommensurability of anarchism and professionalized nursing in its past and current form is clear. Yet, the opportunities for anarchism’s liberatory promise in the context of nursing are profound. Nurses’ physical and tangible abilities to care are subject to the necropolitics of racial capitalism, dictating who must live and who will die [15,16,17]. Anarchist praxis is well aligned with resistance to the carcerality of nursing, hospitals, healthcare, and capitalism. Nurses are miserable, suspended in an endless and futile effort to demonstrate value in a system of violence that cannot and does not value reproductive labor [18,19,20], even when it is the fundamental foundation for healthcare itself. Ground to grist in the mill of the HIC, nurses report rates of anxiety, depression, and stress that are two to more than four times higher than the general population [21]. Even prior to the ongoing COVID-19 pandemic, women who are nurses were twice as likely to die by suicide than their non-nurse peers [21]. Nurses spend exorbitant amounts of time maintaining the capitalist order of the HIC while they are simultaneously shunted to the margins, readily disposed of once expended. This is clearly not without cost.

Through anarchism, nurses might explore a labor stripped “[…] of its deadening, dulling aspect, of its gloom and compulsion… to make work an instrument of joy, of strength, of color, of real harmony, so that the poorest sort of many should in work both recreation and hope” [22] (p. 29). Anarchism gestures toward community survival and mutual aid as it unfolds within Black feminist and Indigenous struggle and survival [23], redolent with potentiality for nursing and care. Central to this effort is the lived understanding that the state is “no longer the horizon of possibility or the telos of struggle” [23] (p. 1), because the state and reigning structures, including professional nursing, are instruments of genocide [24]. We have planted the seeds of the radical vision for the future, and nurse that radical imagination every day, inspired by thinkers and doers and dreamers like Robin D. G. Kelley, Angela Davis, Max Haiven, Ruth Wilson Gilmore, Mariame Kaba, Zena Sharman, and others. For some of our nursing-specific thoughts and the thoughts of our comrades, see [25]. Such visions include all care for all people, a nursing practice freed from the deathworlds in which we currently operate, leaving behind “old visions of conquest and privileges of empire” [26] (p. 8) to instead focus on community, on care, on the world around us. Our interrogation of the terrors and violence of this system operating as currently stands results in one conclusion: This is unacceptable. This vision and a belief in the possibility of “not this” makes every moment of this existence unbearable. We will not tolerate it. Anarchism would be the death of nursing as we know it and it is precisely what nursing needs, what we all need. For the sake of all care for all people, for a radical vision of a world in which we are freed from biopolitical oppressive forces that deform our practice and kill us, abolish nursing [27]!

5. Making the Anarchist Nurse—Tools for the Revolution

In its current state, the nursing profession is ill prepared to reckon with the realities of violence. This violence is already here, has been here. Professionalized nursing is part of the violence, even as it refuses to recognize this. Nurses need skills to recognize this violence as it happens and to resist violence in all its forms, subtle and more overt. Although nurses are ill prepared now to navigate anarchist present/futures, Emma Goldman found nursing an apt career for moving anarchist thought and philosophy into practice. Nursing afforded Goldman unique opportunities to see, understand, and experience the people’s struggles. Because of this proximity to struggle, nursing can be a powerful vehicle by which a liberatory philosophy might translate into meaningful, practical work [28]. Nurses are also quite comfortable with the dynamic complexity of human interaction and experience, in part because nurses work in the muck of the downstream tragedies of existence. Because of this, we think nurses could appreciate the diversity of tools offered by anarchism in meeting individual needs through collective action which requires triage, different strategies for different purposes, and different people, attending to the nuances of people, environments, roles, and occasions. This parallels the ways that more familiar tools of caring diverge, contingent on a variety of variables. For someone birthing a baby, care will be markedly different from the tools required to administer CPR to a person in cardiac arrest—different tools and processes but care just the same.

The American healthcare system often seems immovable, immutable, and innate. Such perceptions shore up the legitimacy of capitalism, assuring the survival of the HIC by erasing its constructedness. And as long as the HIC is considered immovable, immutable, innate, it will remain so. Even nursing professional organization’s more recent willingness to discuss structural violence is subject to this kind of cooptation: ostensibly committed to addressing structural inequity and racism, these efforts also serve as convenient opportunity for institutions to distance themselves from the violence of the imposed Order while also absolving themselves of agency to do anything meaningful about it. An anarchist vision for nursing awakens the reality that institutions cannot be revolutionary; they will not save us. The people that build, uphold, perpetuate the structures (us) must employ an anarchist ontology and make meaning of who we choose to be going forward. Nurses must not only do the anarchy, but cultivate a knowledge, ethics, and practice that is useful in an anarchist world. What does that look like? As Goldman articulated, there is no iron-clad anarchist program to be played out. The social construction of anarchism stands for the “spirit of revolt, in whatever form, against everything that hinders human growth” [22] (p. 21). Once nurses effectively identify what nurses are doing to hinder human growth, nursing can decide what resistance looks like in terms of how, when, where, and who practices nursing, as well as developing tools nurses need along the way, in community with folks who need nursing care.

Before a path can be determined, nurses must commence a robust education that includes an unveiling and unpacking of nursing’s participation and upholding of governmental oppressive structures, past and present. As shared by Lucy Parsons, “anarchists know that a long period of education must precede any great fundamental change in society […]. We look away from government for relief, because we know that that […] from this exercise of force through governments flows nearly all the misery, poverty, crime and confusion existing in society” [29] (p. 31). Calling for Black anarchism and abolition, William Anderson wondered, “So why not embrace the darkness we’re in, the darkness we are, and organize through it and with it? Use the conditions that the state has placed on us to inform our most radical incursions, rather than asking the state to change, when we should know by now that it certainly won’t” [23] (p. xv). This shift will be immensely challenging for nursing, as its professionalized existence is of, by, and for the government. Nurses look to the state to cure their ails with excruciating frequency, abdicating capacity for self-governance, always looking for permission. The State has never delivered on promises of healthcare, safety, equity, and justice. And it never will. Internalizing this lesson gives way to nursing’s responsibility to develop a practice for the people, of which they are an inextricable part [30]. Simultaneously critical is an urgent activation, radicalization, and politicization of nurses to understand the gravity and power of nursing practice in the system that stands today, in service to the worlds we wish to build for tomorrow.

6. Nursing Practice as Direct Action

Martin and Laurin draw on noted anarchist attorney Dean Spade [31] in their assertion that those on the front line of a crisis are best placed to improve outcomes through direct action, writing that direct action “[…] has two requirements, it must be spontaneous and not rely on any regulatory actors, and it must be autonomous, the person must freely decide to act and execute the planned action” [32] (p. 3). Nurses have countless opportunities every day to exercise direct action—if they choose to take them. For example, nurses can refuse to wheel the person without shelter to the curb. Nurses can go to the media to lend their expertise, speak for themselves, and amplify the priorities of nursing. Nurses can blow the whistle on conditions, environments, and practices that jeopardize public safety. Nurses can make sure their uninsured patient returns home with ample wound care supplies. Nurses can refuse to offer information to immigration and detention police. Nurses can choose not to cooperate with legislated mandates that harm patients. Nurses can take their lunch breaks. Nurses can refuse to clock out and refuse to labor unpaid. Nurses can strike.

6.1. Cut the Cop Shit

As we agitate for an anarcho-nurse awakening, we recognize that there are practices that have to go. To embrace anarchist possibilities, nurses will have to end their love affair with what educator Jeffery Moro [33] calls “cop shit.” Speaking about the context of compulsory education, Moro defines cop shit as “any pedagogical technique or technology that presumes an adversarial relationship between students and teachers” (para. 2). Nurse educators Philip Darbyshire and David Thompson took Moro’s cop shit and applied it to nursing education, wondering why “some educators, schools and health services seem to believe that the best way to prepare students and new RNs for this mantle of responsibility is by refusing to trust them at all” [34] (p. 2). Steeped in such an educational tradition, it is little wonder that, upon graduating from nursing school, nurses take cop shit with them to the care environment.

Habituated to cop shit through distrust and control, nurses sometimes project authority over and disdain for the people entrusted to their care. The very notion of “compliance”, common parlance to describe the degree to which someone is cooperating with healthcare orders, is predicated on cop shit, as if the only set of ideas worth thinking with or about are those originating from the HIC. While this might be a more subtle example of cop shit, others are more distinct. Nurses are pressed into service for various law enforcement agencies under the auspices of mandated reporting. Mandated reporting is ostensibly about protecting vulnerable folks but often forces people and families into the carceral structures of the child welfare agencies. Mandated reporting on the basis of perinatal drug screening can lead to incarceration and jeopardy for parental rights. Mandated reporting has taken on new and frightening implications as some states launch legislation that would demand reporting in the context of abortion complications and gender affirming care for some [35]. In the US, these acts of reporting exercise disproportionate harm on Black and brown families [36]. Cop shit has to stop. In its place, nursing could move toward community survival and mutual aid instead.

6.2. Community Survival and Mutual Aid

Some anarchist commitments, such as mutual aid, readily align with the work that nurses do [31]. Mutual aid is defined as “the establishment of systems of care, solidarity, and generosity that arise outside of existing structures of the State and conventional institutions, that are able to ease constraints and foster well-being” [31] (p. 4). Mutual aid is something nurses engage in every day by caring for patients through the support and collaboration of team members. We argue, however, that a key area of imagination and engagement must be devoted to nurses practicing mutual aid beyond and despite the existing structures and conventional institutions. Gaining access to a hospital bed requires a long series of both tragedies and triumphs. Nurses must get out of the hospital and venture into the streets to understand and explore what mutual aid and community survival looks like and what it could look like if and when more nurses break down institutional walls.

We have examples of anarchism in caring practice to draw from: those stories that have survived attempts at institutional forgetting and silencing, such as Black nurse and activist Marie Branch’s brave implementation of antiracist philosophy and practice, even in such obstructionist environments as the American Nurses Association [37]. Her co-founding of the Los Angeles Black Panther Party’s Free Clinic in 1969 [38] was demonstrative of her belief that nursing could free itself from a practice dictated by payment models and elitist structures [39]. Following Saidiya Hartman, we recognize that nurse Harriet Tubman and her Underground Railroad represent an anarchist “‘inheritance’ of the dispossessed, the legacy of slaves and fugitives, toilers and recalcitrant domestics […] the history that arrives with us—as those who exist outside the nation, as the stateless, as the dead, as property, as objects and tools, as sentient flesh” (p. xvii), pointing to a critical legacy of refusal and resistance and survival related to care, with lessons for nursing, if nursing should choose to see [40]. There are others, known and unknown, who enacted anarchist caring practices as fugitives from the institution, to bring caring practice to the people, for the people, and to help one another survive another day.

6.3. Militant Joy

One of the most vital ways we sustain ourselves is by building communities of resistance, places where we know we are not alone.

[41]

Joy is not the first word that comes to mind when it comes to nursing, nor is it revolution. Nursing can be joyful. Certainly, attending births and connecting with folks for whom we care and nurturing students as they learn and grow comes with relation, joy, community—good feelings. Even attending deaths can be resonant and rich in their connection and support, even if “joy” might not be the right emotion to express what is happening. However, there is little space for joy in nursing under capitalist regimes; every band aid, acetaminophen tablet, piece of gauze, minute on the clock, step in the hospital is metricized. Every dollar squeezed. Every hospital day scrutinized. But sad people are easily managed, more readily docile. Making the case for joyful militancy, bergman et al. explained that the “empire’s hold is increasingly affective: it suffuses our emotions, relationships, and desires, propagating feelings of shame, impotence, fear, and dependence. It makes capitalist relations feel inevitable and (to some) even desirable” [42] (p. 51). This affective hold demands conformity, which is readily conferred as a product of the quality of immutability of institutions in capitalism, in empire.

Rather than succumbing to the alienation and estrangement of nursing under capitalism [43], we might instead recognize that “joy is a desubjectifying process, an unfixing, an intensification of life itself” [42]. Enlivening in the faults and fissures of systems as they presently exist, joy is expansive, generative, and animating. Rooted in the co-constitution of feeling and thinking (and doing), joy lives in potential, in community, in struggle, in resistance, in care, and in nursing [42]. Anarchism offers this up, not as a way to avoid pain or strife or hard work but rather “to embrace the conviviality and joy that comes with being together as radical equals, not as vanguards and proletariat on the path towards the transcendental empty promise of utopia or ‘no place’, but as the grounded immanence of the here and now of actually making a new world ‘in the shell of the old’” [44] (p. 288). Acknowledging the personal risk associated with the ideas we are advancing in the present, we cannot help but be renewed in our own praxes of hope by the possibilities of what we could build, together.

Nurses and the folks who need their care must find spaces and communities to celebrate, laugh, cry, love and challenge one another, and find joy. We must find one another in order to cultivate community so that when one needs rest, another can take up the charge. Collectively and militantly practicing hope, joy, and a radical vision for what nursing could be if we chose to make it is in fact one of the most important acts of resistance of all. We must find others who refuse to accept that the profession and work that has hurt us and the people we care for so severely is all that nursing will ever be. There is danger in sharpening nurses as instruments of resistance; it risks healthcare as we know it today, and it risks the crumbling of an empire. We will need, need today, to cultivate communities of care, because times are hard and becoming harder all the time.

7. Conclusions

Nothing we propose here is new. Black, Indigenous, queer, and poor communities’ very existence have been anarchy in practice since the dawn of this country’s borders and long before [41]. The realities we see unfolding in front of us are uncomfortably clear: states are failing, including the United States. Hospitals are failing, and professionalized nursing as we know it today, is failing. Nurses are ill prepared to reckon with the realities of how we might expect violence (especially institutional and state-sanctioned violence) to escalate. This violence is already here and has been here. Violence is apt to escalate as authoritarianism continues to rise, as the human-driven climate catastrophe continues unabated, as people flee hostile weather disasters, as resources grow scarcer, as disease and pestilence arise from increasing human–wildlife encounters, and as colonized people rise up. The skill set that nurses need to develop includes recognizing violence as it happens and resisting violence as it becomes more overt. Nurses have tremendous potential to help one another survive, but we must recognize the crisis before us and—critically—believe in our collective capacity to build a better world. The moment we stop believing in our capacity to shift realities is the moment it ceases to be possible.

La beauté est dans la rue: Out of the hospital, into the streets.